| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $99 | N/A | $99 |
| Dental Exam - Comprehensive | $135 | N/A | $135 |
| Dental Exam - Periodic, Established Patient | $67 | N/A | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $247 | N/A | $247 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $405 | N/A | $405 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $323 | N/A | $323 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $405 | N/A | $405 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $270 | N/A | $270 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | N/A | $323 |
| Flouride - Topical Varnish Application | $61 | N/A | $61 |
| Fluoride - Topical Application | $61 | N/A | $61 |
| Maintenance Therapy - Periodontal | $170 | N/A | $170 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | N/A | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | N/A | $114 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | N/A | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | N/A | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | N/A | $48 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | N/A | $184 |
