| Dental Cleaning - Adult | $140 | N/A | $140 |
| Dental Cleaning - Child | $106 | N/A | $106 |
| Dental Exam - Comprehensive | $163 | N/A | $163 |
| Dental Exam - Periodic, Established Patient | $83 | N/A | $83 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $178 | N/A | $178 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $419 | N/A | $419 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $335 | N/A | $335 |
| Dental Filling - White (Resin): One Surface, Anterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): One Surface, Posterior | $268 | N/A | $268 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | N/A | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $296 | N/A | $296 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $335 | N/A | $335 |
| Flouride - Topical Varnish Application | $62 | N/A | $62 |
| Fluoride - Topical Application | $40 | N/A | $40 |
| Maintenance Therapy - Periodontal | $202 | N/A | $202 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | N/A | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $134 | N/A | $134 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | N/A | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $308 | N/A | $308 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $44 | N/A | $44 |
| X-Ray - Complete Intraoral Series | $212 | N/A | $212 |
| X-Ray - Four Images, Bitewings | $101 | N/A | $101 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $202 | N/A | $202 |
