| Dental Cleaning - Adult | $189 | N/A | $189 |
| Dental Cleaning - Child | $145 | N/A | $145 |
| Dental Exam - Comprehensive | $145 | N/A | $145 |
| Dental Exam - Periodic, Established Patient | $88 | N/A | $88 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | N/A | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | N/A | $298 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $473 | N/A | $473 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $328 | N/A | $328 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | N/A | $389 |
| Fluoride - Topical Application | $84 | N/A | $84 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | N/A | $137 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $97 | N/A | $97 |
| Tooth Extraction - Elevation and/or Forceps Removal | $274 | N/A | $274 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | N/A | $21 |
| X-Ray - Complete Intraoral Series | $265 | N/A | $265 |
| X-Ray - Four Images, Bitewings | $113 | N/A | $113 |
| X-Ray - Intraoral, Periapical Radiographic Image | $61 | N/A | $61 |
| X-Ray - Two Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
