| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $182 | N/A | $182 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $254 | N/A | $254 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $312 | N/A | $312 |
| Dental Filling - White (Resin): One Surface, Anterior | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Posterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | N/A | $312 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $205 | N/A | $205 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $312 | N/A | $312 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Tooth Extraction - Elevation and/or Forceps Removal | $289 | N/A | $289 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $98 | N/A | $98 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | N/A | $49 |
| X-Ray - Two Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $180 | N/A | $180 |
