| Dental Cleaning - Adult | $133 | N/A | $133 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $77 | N/A | $77 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | N/A | $237 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $266 | N/A | $266 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | N/A | $289 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | N/A | $289 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $347 | N/A | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $151 | N/A | $151 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | N/A | $82 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $210 | N/A | $210 |
| X-Ray - Four Images, Bitewings | $142 | N/A | $142 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | N/A | $49 |
| X-Ray - Two Images, Bitewings | $97 | N/A | $97 |
