| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $98 | N/A | $98 |
| Dental Exam - Comprehensive | $106 | N/A | $106 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $401 | N/A | $401 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | N/A | $308 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $401 | N/A | $401 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | N/A | $308 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Oral Hygiene Instructions | $68 | N/A | $68 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $234 | N/A | $234 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $151 | N/A | $151 |
