| Dental Cleaning - Adult | $102 | N/A | $102 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $422 | N/A | $422 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $163 | N/A | $163 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | N/A | $221 |
| Fluoride - Topical Application | $38 | N/A | $38 |
| Maintenance Therapy - Periodontal | $130 | N/A | $130 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $259 | N/A | $259 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $122 | N/A | $122 |
| Tooth Extraction - Elevation and/or Forceps Removal | $277 | N/A | $277 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $233 | N/A | $233 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
