| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $78 | N/A | $78 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $458 | N/A | $458 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $345 | N/A | $345 |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $261 | N/A | $261 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $458 | N/A | $458 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $345 | N/A | $345 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $345 | N/A | $345 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $404 | N/A | $404 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | N/A | $126 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | N/A | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | N/A | $47 |
| X-Ray - Complete Intraoral Series | $198 | N/A | $198 |
| X-Ray - Four Images, Bitewings | $147 | N/A | $147 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $97 | N/A | $97 |
