| Dental Cleaning - Adult | $139 | N/A | $139 |
| Dental Cleaning - Child | $113 | N/A | $113 |
| Dental Exam - Comprehensive | $163 | N/A | $163 |
| Dental Exam - Periodic, Established Patient | $72 | N/A | $72 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $378 | N/A | $378 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | N/A | $378 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | N/A | $315 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $205 | N/A | $205 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | N/A | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | N/A | $126 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | N/A | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $56 | N/A | $56 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | N/A | $184 |
