| Dental Cleaning - Adult | $93 | N/A | $93 |
| Dental Cleaning - Child | $68 | N/A | $68 |
| Dental Exam - Comprehensive | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | N/A | $281 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Oral Hygiene Instructions | $47 | N/A | $47 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | N/A | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | N/A | $74 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | N/A | $53 |
| Tooth Extraction - Elevation and/or Forceps Removal | $160 | N/A | $160 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | N/A | $21 |
| X-Ray - Complete Intraoral Series | $125 | N/A | $125 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Whole Mouth from Outside Mouth | $110 | N/A | $110 |
