| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | N/A | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | N/A | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | N/A | $277 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $331 | N/A | $331 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | N/A | $277 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | N/A | $165 |
