| Dental Cleaning - Adult | $129 | N/A | $129 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $129 | N/A | $129 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | N/A | $415 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $349 | N/A | $349 |
| Dental Filling - White (Resin): One Surface, Anterior | $234 | N/A | $234 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $339 | N/A | $339 |
| Flouride - Topical Varnish Application | $62 | N/A | $62 |
| Maintenance Therapy - Periodontal | $189 | N/A | $189 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | N/A | $93 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $355 | N/A | $355 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $257 | N/A | $257 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $108 | N/A | $108 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
