| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $366 | N/A | $366 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $54 | N/A | $54 |
| Fluoride - Topical Application | $39 | N/A | $39 |
| Maintenance Therapy - Periodontal | $149 | N/A | $149 |
| Oral Hygiene Instructions | $41 | N/A | $41 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $164 | N/A | $164 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $295 | N/A | $295 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $238 | N/A | $238 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $150 | N/A | $150 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| 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 | $150 | N/A | $150 |
