| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| 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 | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $187 | N/A | $187 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | N/A | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | N/A | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | N/A | $182 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $191 | N/A | $191 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $128 | N/A | $128 |
