| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $72 | N/A | $72 |
| Dental Exam - Comprehensive | $77 | N/A | $77 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $271 | N/A | $271 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $156 | N/A | $156 |
| Dental Filling - White (Resin): One Surface, Anterior | $140 | N/A | $140 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $131 | N/A | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $235 | N/A | $235 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | N/A | $75 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | N/A | $49 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | N/A | $155 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $125 | N/A | $125 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $44 | N/A | $44 |
| X-Ray - Whole Mouth from Outside Mouth | $123 | N/A | $123 |
