| Dental Cleaning - Adult | $101 | N/A | $101 |
| Dental Cleaning - Child | $76 | N/A | $76 |
| Dental Exam - Comprehensive | $78 | N/A | $78 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | N/A | $239 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $248 | N/A | $248 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $207 | N/A | $207 |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | N/A | $147 |
| Dental Filling - White (Resin): One Surface, Posterior | $161 | N/A | $161 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $277 | N/A | $277 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $181 | N/A | $181 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $211 | N/A | $211 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $71 | N/A | $71 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $164 | N/A | $164 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | N/A | $23 |
| X-Ray - Complete Intraoral Series | $142 | N/A | $142 |
| X-Ray - Four Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $44 | N/A | $44 |
| X-Ray - Whole Mouth from Outside Mouth | $118 | N/A | $118 |
