| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $109 | 0% | $109 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $67 | 0% | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $417 | 0% | $417 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $338 | 0% | $338 |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | 0% | $417 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | 0% | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $338 | 0% | $338 |
| Flouride - Topical Varnish Application | $54 | 0% | $54 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $66 | 0% | $66 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | 0% | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $243 | 0% | $243 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $54 | 0% | $54 |
| X-Ray - Complete Intraoral Series | $190 | 0% | $190 |
| X-Ray - Four Images, Bitewings | $102 | 0% | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | 0% | $60 |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
