| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | N/A | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $166 | N/A | $166 |
| 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 | $95 | N/A | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | N/A | $240 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
