| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $162 | N/A | $162 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $280 | N/A | $280 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $264 | N/A | $264 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $280 | N/A | $280 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $223 | N/A | $223 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $207 | N/A | $207 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | N/A | $51 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | N/A | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | N/A | $216 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $146 | N/A | $146 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
