| Dental Cleaning - Adult | $138 | N/A | $138 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | N/A | $249 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $454 | N/A | $454 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $349 | N/A | $349 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | N/A | $249 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $454 | N/A | $454 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | N/A | $266 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $349 | N/A | $349 |
| Fluoride - Topical Application | $60 | N/A | $60 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $119 | N/A | $119 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $85 | N/A | $85 |
| Tooth Extraction - Elevation and/or Forceps Removal | $266 | N/A | $266 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $280 | N/A | $280 |
| X-Ray - Four Images, Bitewings | $99 | N/A | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | N/A | $43 |
| X-Ray - Two Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | N/A | $182 |
