| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $626 | N/A | $626 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $525 | N/A | $525 |
| Dental Filling - White (Resin): One Surface, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Oral Hygiene Instructions | $26 | N/A | $26 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $91 | N/A | $91 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | N/A | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $126 | N/A | $126 |
| Tooth Extraction - Elevation and/or Forceps Removal | $389 | N/A | $389 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $205 | N/A | $205 |
| X-Ray - Four Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $79 | N/A | $79 |
