| Dental Cleaning - Adult | $132 | N/A | $132 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $308 | N/A | $308 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $424 | N/A | $424 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $410 | N/A | $410 |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): One Surface, Posterior | $308 | N/A | $308 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $424 | N/A | $424 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $410 | N/A | $410 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $317 | N/A | $317 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | N/A | $114 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | N/A | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $171 | N/A | $171 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $159 | N/A | $159 |
