| Dental Cleaning - Adult | $148 | N/A | $148 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $130 | N/A | $130 |
| Dental Exam - Periodic, Established Patient | $80 | N/A | $80 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $238 | N/A | $238 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $379 | N/A | $379 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $296 | N/A | $296 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | N/A | $238 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $320 | N/A | $320 |
| Flouride - Topical Varnish Application | $66 | N/A | $66 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $188 | N/A | $188 |
| X-Ray - Four Images, Bitewings | $96 | N/A | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
