| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | N/A | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $21 | N/A | $21 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
