| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | N/A | $176 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $180 | N/A | $180 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Flouride - Topical Varnish Application | $32 | N/A | $32 |
| Fluoride - Topical Application | $32 | N/A | $32 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $248 | N/A | $248 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | N/A | $179 |
