| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $149 | N/A | $149 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | N/A | $355 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | N/A | $278 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
