| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $78 | N/A | $78 |
| Dental Exam - Comprehensive | $137 | N/A | $137 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | N/A | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | N/A | $294 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $156 | N/A | $156 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | N/A | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $67 | N/A | $67 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
