| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $400 | 0% | $400 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | 0% | $68 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
