| Dental Cleaning - Adult | $144 | N/A | $144 |
| Dental Cleaning - Child | $123 | N/A | $123 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $100 | N/A | $100 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | N/A | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): One Surface, Posterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | N/A | $313 |
| Fluoride - Topical Application | $81 | N/A | $81 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | N/A | $83 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $51 | N/A | $51 |
| X-Ray - Complete Intraoral Series | $226 | N/A | $226 |
| X-Ray - Four Images, Bitewings | $142 | N/A | $142 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | N/A | $60 |
| X-Ray - Two Images, Bitewings | $104 | N/A | $104 |
| X-Ray - Whole Mouth from Outside Mouth | $299 | N/A | $299 |
