| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $525 | 0% | $525 |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | 0% | $213 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $91 | 0% | $91 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $200 | 0% | $200 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $389 | 0% | $389 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $205 | 0% | $205 |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Whole Mouth from Outside Mouth | $205 | 0% | $205 |
