| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $117 | N/A | $117 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $302 | N/A | $302 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | N/A | $404 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $253 | N/A | $253 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | N/A | $311 |
| Flouride - Topical Varnish Application | $61 | N/A | $61 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $151 | N/A | $151 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $62 | N/A | $62 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $146 | N/A | $146 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
