| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | N/A | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | N/A | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $118 | N/A | $118 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | N/A | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | N/A | $135 |
