| Dental Cleaning - Adult | $101 | N/A | $101 |
| Dental Cleaning - Child | $75 | N/A | $75 |
| Dental Exam - Comprehensive | $87 | N/A | $87 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $149 | N/A | $149 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $312 | N/A | $312 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $255 | N/A | $255 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $312 | N/A | $312 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $255 | N/A | $255 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $252 | N/A | $252 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
