| Dental Cleaning - Adult | $86 | N/A | $86 |
| Dental Cleaning - Child | $63 | N/A | $63 |
| Dental Exam - Comprehensive | $82 | N/A | $82 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $152 | N/A | $152 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Anterior | $144 | N/A | $144 |
| Dental Filling - White (Resin): One Surface, Posterior | $305 | N/A | $305 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | N/A | $345 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | N/A | $389 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | N/A | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | N/A | $158 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $193 | N/A | $193 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $46 | N/A | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $120 | N/A | $120 |
