| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | N/A | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | N/A | $266 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $214 | N/A | $214 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | N/A | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | N/A | $286 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $330 | N/A | $330 |
| Oral Hygiene Instructions | $55 | N/A | $55 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | N/A | $225 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $155 | N/A | $155 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
