| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | 0% | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | 0% | $197 |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $116 | 0% | $116 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | 0% | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
