| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $180 | N/A | $180 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $312 | N/A | $312 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Posterior | $180 | N/A | $180 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | N/A | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | N/A | $259 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $164 | N/A | $164 |
| 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 | $104 | N/A | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $156 | N/A | $156 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $162 | N/A | $162 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
