| Dental Cleaning - Adult | $132 | N/A | $132 |
| Dental Cleaning - Child | $109 | N/A | $109 |
| Dental Exam - Comprehensive | $114 | N/A | $114 |
| Dental Exam - Periodic, Established Patient | $67 | N/A | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $417 | N/A | $417 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $338 | N/A | $338 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $425 | N/A | $425 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | N/A | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $338 | N/A | $338 |
| Flouride - Topical Varnish Application | $54 | N/A | $54 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | N/A | $68 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | N/A | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | N/A | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $243 | N/A | $243 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $54 | N/A | $54 |
| X-Ray - Complete Intraoral Series | $190 | N/A | $190 |
| X-Ray - Four Images, Bitewings | $102 | N/A | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | N/A | $60 |
| X-Ray - Two Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | N/A | $179 |
