| Dental Cleaning - Adult | $147 | N/A | $147 |
| Dental Cleaning - Child | $126 | N/A | $126 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $105 | N/A | $105 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Fluoride - Topical Application | $63 | N/A | $63 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $53 | N/A | $53 |
| X-Ray - Complete Intraoral Series | $210 | N/A | $210 |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | N/A | $53 |
| X-Ray - Two Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
