| Dental Cleaning - Adult | $152 | N/A | $152 |
| Dental Cleaning - Child | $106 | N/A | $106 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $423 | N/A | $423 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - White (Resin): One Surface, Anterior | $251 | N/A | $251 |
| Dental Filling - White (Resin): One Surface, Posterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $423 | N/A | $423 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $285 | N/A | $285 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $344 | N/A | $344 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $337 | N/A | $337 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $106 | N/A | $106 |
| Tooth Extraction - Elevation and/or Forceps Removal | $298 | N/A | $298 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $225 | N/A | $225 |
| X-Ray - Four Images, Bitewings | $106 | N/A | $106 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Whole Mouth from Outside Mouth | $198 | N/A | $198 |
