| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - White (Resin): One Surface, Anterior | $336 | 0% | $336 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $411 | 0% | $411 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $334 | 0% | $334 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $79 | 0% | $79 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | 0% | $336 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $120 | 0% | $120 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $357 | 0% | $357 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $174 | 0% | $174 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $294 | 0% | $294 |
