| Dental Cleaning - Adult | $113 | N/A | $113 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $99 | N/A | $99 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | N/A | $394 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $446 | N/A | $446 |
| Dental Filling - White (Resin): One Surface, Anterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): One Surface, Posterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | N/A | $394 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $342 | N/A | $342 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $265 | N/A | $265 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | N/A | $326 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | N/A | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $155 | N/A | $155 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
