| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | N/A | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $296 | N/A | $296 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | N/A | $282 |
| Flouride - Topical Varnish Application | $38 | N/A | $38 |
| Maintenance Therapy - Periodontal | $142 | N/A | $142 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $268 | N/A | $268 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | N/A | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $172 | N/A | $172 |
| X-Ray - Four Images, Bitewings | $90 | N/A | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | N/A | $48 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
