| Dental Cleaning - Adult | $133 | N/A | $133 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | N/A | $289 |
| Flouride - Topical Varnish Application | $74 | N/A | $74 |
| Fluoride - Topical Application | $53 | N/A | $53 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $159 | N/A | $159 |
| Tooth Extraction - Elevation and/or Forceps Removal | $352 | N/A | $352 |
| X-Ray - Complete Intraoral Series | $210 | N/A | $210 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $77 | N/A | $77 |
