| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | N/A | $282 |
| Flouride - Topical Varnish Application | $40 | N/A | $40 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | N/A | $273 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | N/A | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $156 | N/A | $156 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
