| Dental Cleaning - Adult | $130 | N/A | $130 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $71 | N/A | $71 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $275 | N/A | $275 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $71 | N/A | $71 |
| Maintenance Therapy - Periodontal | $190 | N/A | $190 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $161 | N/A | $161 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Complete Intraoral Series | $200 | N/A | $200 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $78 | N/A | $78 |
