| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $43 | N/A | $43 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | N/A | $368 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $173 | N/A | $173 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | N/A | $259 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $154 | N/A | $154 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $155 | N/A | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | N/A | $23 |
| X-Ray - Complete Intraoral Series | $164 | N/A | $164 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
