| Dental Cleaning - Adult | $113 | N/A | $113 |
| Dental Cleaning - Child | $117 | N/A | $117 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $40 | N/A | $40 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | N/A | $245 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $245 | N/A | $245 |
| Flouride - Topical Varnish Application | $59 | N/A | $59 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | N/A | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | N/A | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $218 | N/A | $218 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
