| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | N/A | $173 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | N/A | $315 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Fluoride - Topical Application | $71 | N/A | $71 |
| Maintenance Therapy - Periodontal | $231 | N/A | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $175 | N/A | $175 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
