| Dental Cleaning - Adult | $87 | 0% | $87 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | 0% | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
| Fluoride - Topical Application | $41 | 0% | $41 |
| Maintenance Therapy - Periodontal | $127 | 0% | $127 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $155 | 0% | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $394 | 0% | $394 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
| X-Ray - Complete Intraoral Series | $193 | 0% | $193 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
