| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $119 | N/A | $119 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | N/A | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $328 | N/A | $328 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $267 | N/A | $267 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $328 | N/A | $328 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $267 | N/A | $267 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $267 | N/A | $267 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $394 | N/A | $394 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $132 | N/A | $132 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Four Images, Bitewings | $87 | N/A | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
