| Dental Cleaning - Adult | $106 | 0% | $106 |
| Dental Cleaning - Child | $101 | 0% | $101 |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $253 | 0% | $253 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | 0% | $311 |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
| Fluoride - Topical Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $62 | 0% | $62 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
