| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $97 | N/A | $97 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $54 | N/A | $54 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $126 | N/A | $126 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | N/A | $276 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | N/A | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $204 | N/A | $204 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
