| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $176 | N/A | $176 |
| Dental Exam - Comprehensive | $121 | N/A | $121 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $258 | N/A | $258 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | N/A | $404 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $280 | N/A | $280 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $258 | N/A | $258 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $685 | N/A | $685 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $251 | N/A | $251 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $280 | N/A | $280 |
| Fluoride - Topical Application | $56 | N/A | $56 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $352 | N/A | $352 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Tooth Extraction - Elevation and/or Forceps Removal | $268 | N/A | $268 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $181 | N/A | $181 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
