| Dental Cleaning - Adult | $140 | N/A | $140 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $139 | N/A | $139 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $299 | N/A | $299 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $436 | N/A | $436 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $362 | N/A | $362 |
| Dental Filling - White (Resin): One Surface, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $436 | N/A | $436 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $362 | N/A | $362 |
| Flouride - Topical Varnish Application | $79 | N/A | $79 |
| Maintenance Therapy - Periodontal | $215 | N/A | $215 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | N/A | $121 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $299 | N/A | $299 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $46 | N/A | $46 |
| X-Ray - Complete Intraoral Series | $231 | N/A | $231 |
| X-Ray - Four Images, Bitewings | $99 | N/A | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
