| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $98 | N/A | $98 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $159 | N/A | $159 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $302 | N/A | $302 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $240 | N/A | $240 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | N/A | $369 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $163 | N/A | $163 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | N/A | $306 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $407 | N/A | $407 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $203 | N/A | $203 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | N/A | $140 |
