| Dental Cleaning - Adult | $128 | N/A | $128 |
| Dental Cleaning - Child | $98 | N/A | $98 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $71 | N/A | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | N/A | $374 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $311 | N/A | $311 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | N/A | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $268 | N/A | $268 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | N/A | $311 |
| Flouride - Topical Varnish Application | $59 | N/A | $59 |
| Maintenance Therapy - Periodontal | $188 | N/A | $188 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $334 | N/A | $334 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Complete Intraoral Series | $174 | N/A | $174 |
| X-Ray - Four Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Whole Mouth from Outside Mouth | $155 | N/A | $155 |
