| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $179 | N/A | $179 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | N/A | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $393 | N/A | $393 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $537 | N/A | $537 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $270 | N/A | $270 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | N/A | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $126 | N/A | $126 |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | N/A | $251 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $179 | N/A | $179 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $116 | N/A | $116 |
