| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | N/A | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | N/A | $266 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $329 | N/A | $329 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | N/A | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $271 | N/A | $271 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $65 | N/A | $65 |
| Maintenance Therapy - Periodontal | $171 | N/A | $171 |
| Oral Hygiene Instructions | $62 | N/A | $62 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | N/A | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | N/A | $53 |
| Tooth Extraction - Elevation and/or Forceps Removal | $204 | N/A | $204 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $205 | N/A | $205 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
