| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| 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 | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $353 | N/A | $353 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $110 | N/A | $110 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | N/A | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | N/A | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
