| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $131 | N/A | $131 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | N/A | $84 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | N/A | $55 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
