| Dental Cleaning - Adult | $117 | N/A | $117 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $400 | N/A | $400 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $307 | N/A | $307 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $380 | N/A | $380 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | N/A | $307 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | N/A | $51 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $307 | N/A | $307 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $224 | N/A | $224 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $144 | N/A | $144 |
