| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | 0% | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Fluoride - Topical Application | $58 | 0% | $58 |
| Maintenance Therapy - Periodontal | $186 | 0% | $186 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | 0% | $336 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $248 | 0% | $248 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
