| Dental Cleaning - Adult | $137 | 0% | $137 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | 0% | $378 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $135 | 0% | $135 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | 0% | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $242 | 0% | $242 |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
| X-Ray - Two Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Whole Mouth from Outside Mouth | $236 | 0% | $236 |
