| Dental Cleaning - Adult | $102 | N/A | $102 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $196 | N/A | $196 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | N/A | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | N/A | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | N/A | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $143 | N/A | $143 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
