| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | N/A | $378 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | N/A | $307 |
| Flouride - Topical Varnish Application | $63 | N/A | $63 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $81 | N/A | $81 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $176 | N/A | $176 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | N/A | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | N/A | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $242 | N/A | $242 |
| X-Ray - Four Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Whole Mouth from Outside Mouth | $236 | N/A | $236 |
