| Dental Cleaning - Adult | $135 | N/A | $135 |
| Dental Cleaning - Child | $113 | N/A | $113 |
| Dental Exam - Comprehensive | $124 | N/A | $124 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $433 | N/A | $433 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $339 | N/A | $339 |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | N/A | $223 |
| Dental Filling - White (Resin): One Surface, Posterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | N/A | $433 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $339 | N/A | $339 |
| Flouride - Topical Varnish Application | $61 | N/A | $61 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $83 | N/A | $83 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $119 | N/A | $119 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | N/A | $265 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | N/A | $43 |
| X-Ray - Complete Intraoral Series | $222 | N/A | $222 |
| X-Ray - Four Images, Bitewings | $98 | N/A | $98 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | N/A | $48 |
| X-Ray - Two Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $173 | N/A | $173 |
