| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $291 | N/A | $291 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $445 | N/A | $445 |
| Dental Filling - White (Resin): One Surface, Anterior | $336 | N/A | $336 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $411 | N/A | $411 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $334 | N/A | $334 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $185 | N/A | $185 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $79 | N/A | $79 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | N/A | $336 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $357 | N/A | $357 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $174 | N/A | $174 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $294 | N/A | $294 |
