| Dental Cleaning - Adult | $95 | N/A | $95 |
| Dental Cleaning - Child | $68 | N/A | $68 |
| Dental Exam - Comprehensive | $122 | N/A | $122 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | N/A | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $317 | N/A | $317 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Flouride - Topical Varnish Application | $38 | N/A | $38 |
| Fluoride - Topical Application | $38 | N/A | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | N/A | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
