| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $197 | N/A | $197 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | N/A | $266 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): One Surface, Posterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $380 | N/A | $380 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $248 | N/A | $248 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | N/A | $293 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $175 | N/A | $175 |
| Oral Hygiene Instructions | $47 | N/A | $47 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $327 | N/A | $327 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | N/A | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $212 | N/A | $212 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $179 | N/A | $179 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | N/A | $179 |
