| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Comprehensive | $162 | N/A | $162 |
| Dental Exam - Periodic, Established Patient | $77 | N/A | $77 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $420 | N/A | $420 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $420 | N/A | $420 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | N/A | $278 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $347 | N/A | $347 |
| Flouride - Topical Varnish Application | $65 | N/A | $65 |
| Fluoride - Topical Application | $65 | N/A | $65 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | N/A | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $259 | N/A | $259 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | N/A | $49 |
| X-Ray - Two Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | N/A | $165 |
