| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $300 | N/A | $300 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $159 | N/A | $159 |
| Oral Hygiene Instructions | $45 | N/A | $45 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $69 | N/A | $69 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $322 | N/A | $322 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | N/A | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $156 | N/A | $156 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | N/A | $138 |
