| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $296 | N/A | $296 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | N/A | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | N/A | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | N/A | $279 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | N/A | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | N/A | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $222 | N/A | $222 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
