| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $179 | N/A | $179 |
| Dental Exam - Comprehensive | $82 | N/A | $82 |
| Dental Exam - Periodic, Established Patient | $46 | N/A | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $293 | N/A | $293 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $323 | N/A | $323 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Flouride - Topical Varnish Application | $92 | N/A | $92 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | N/A | $242 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | N/A | $22 |
| X-Ray - Complete Intraoral Series | $176 | N/A | $176 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
