| Dental Cleaning - Adult | $145 | N/A | $145 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $254 | N/A | $254 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | N/A | $315 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Complete Intraoral Series | $167 | N/A | $167 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
