| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $380 | N/A | $380 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | N/A | $354 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $531 | N/A | $531 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | N/A | $278 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $156 | N/A | $156 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $98 | N/A | $98 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | N/A | $288 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| 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 | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $162 | N/A | $162 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $162 | N/A | $162 |
