| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | N/A | $352 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | N/A | $270 |
| Dental Filling - White (Resin): One Surface, Anterior | $180 | N/A | $180 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | N/A | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | N/A | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $186 | N/A | $186 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
