| Dental Cleaning - Adult | $130 | N/A | $130 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $121 | N/A | $121 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $408 | N/A | $408 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | N/A | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | N/A | $408 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $314 | N/A | $314 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Flouride - Topical Varnish Application | $68 | N/A | $68 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $69 | N/A | $69 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | N/A | $111 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | N/A | $218 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $216 | N/A | $216 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $159 | N/A | $159 |
