| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | N/A | $259 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $146 | N/A | $146 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | N/A | $129 |
