| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $187 | N/A | $187 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | N/A | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $98 | N/A | $98 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $204 | N/A | $204 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
