| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | N/A | $270 |
| Dental Filling - White (Resin): One Surface, Anterior | $193 | N/A | $193 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $158 | N/A | $158 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $383 | N/A | $383 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
