| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Comprehensive | $97 | N/A | $97 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $398 | N/A | $398 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $300 | N/A | $300 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $398 | N/A | $398 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | N/A | $297 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $197 | N/A | $197 |
| 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 | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
