| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $45 | 0% | $45 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $162 | 0% | $162 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $280 | 0% | $280 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - White (Resin): One Surface, Anterior | $154 | 0% | $154 |
| Dental Filling - White (Resin): One Surface, Posterior | $162 | 0% | $162 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $280 | 0% | $280 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $192 | 0% | $192 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $223 | 0% | $223 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $198 | 0% | $198 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | 0% | $216 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $146 | 0% | $146 |
