| Dental Cleaning - Adult | $206 | N/A | $206 |
| Dental Cleaning - Child | $169 | N/A | $169 |
| Dental Exam - Comprehensive | $189 | N/A | $189 |
| Dental Exam - Periodic, Established Patient | $105 | N/A | $105 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $372 | N/A | $372 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $519 | N/A | $519 |
| Dental Filling - White (Resin): One Surface, Posterior | $372 | N/A | $372 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $674 | N/A | $674 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $414 | N/A | $414 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $519 | N/A | $519 |
| Flouride - Topical Varnish Application | $101 | N/A | $101 |
| Maintenance Therapy - Periodontal | $336 | N/A | $336 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $544 | N/A | $544 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $174 | N/A | $174 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $116 | N/A | $116 |
| Tooth Extraction - Elevation and/or Forceps Removal | $435 | N/A | $435 |
| X-Ray - Complete Intraoral Series | $288 | N/A | $288 |
| X-Ray - Four Images, Bitewings | $151 | N/A | $151 |
| X-Ray - Intraoral, Periapical Radiographic Image | $67 | N/A | $67 |
| X-Ray - Two Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Whole Mouth from Outside Mouth | $275 | N/A | $275 |
