| Dental Cleaning - Adult | $133 | N/A | $133 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $117 | N/A | $117 |
| Dental Exam - Periodic, Established Patient | $70 | N/A | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | N/A | $377 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | N/A | $309 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | N/A | $377 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | N/A | $309 |
| Flouride - Topical Varnish Application | $62 | N/A | $62 |
| Maintenance Therapy - Periodontal | $198 | N/A | $198 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $339 | N/A | $339 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | N/A | $109 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | N/A | $251 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $208 | N/A | $208 |
| X-Ray - Four Images, Bitewings | $93 | N/A | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
