| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $111 | N/A | $111 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | N/A | $352 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | N/A | $282 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $139 | N/A | $139 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $164 | N/A | $164 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Whole Mouth from Outside Mouth | $263 | N/A | $263 |
