| Dental Cleaning - Adult | $129 | N/A | $129 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $106 | N/A | $106 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $280 | N/A | $280 |
| Dental Filling - White (Resin): One Surface, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): One Surface, Posterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $334 | N/A | $334 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | N/A | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | N/A | $315 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $186 | N/A | $186 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
