| Dental Cleaning - Adult | $101 | N/A | $101 |
| Dental Cleaning - Child | $72 | N/A | $72 |
| Dental Exam - Comprehensive | $77 | N/A | $77 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | N/A | $186 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | N/A | $186 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | N/A | $259 |
| Flouride - Topical Varnish Application | $65 | N/A | $65 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $244 | N/A | $244 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Tooth Extraction - Elevation and/or Forceps Removal | $291 | N/A | $291 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $139 | N/A | $139 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $27 | N/A | $27 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
