| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $268 | N/A | $268 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $494 | N/A | $494 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $331 | N/A | $331 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | N/A | $247 |
| Fluoride - Topical Application | $39 | N/A | $39 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $69 | N/A | $69 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | N/A | $74 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | N/A | $158 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $173 | N/A | $173 |
| X-Ray - Four Images, Bitewings | $137 | N/A | $137 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
