| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $154 | N/A | $154 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $272 | N/A | $272 |
| Dental Filling - White (Resin): One Surface, Anterior | $185 | N/A | $185 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | N/A | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $171 | N/A | $171 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $167 | N/A | $167 |
