| Dental Cleaning - Adult | $144 | N/A | $144 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $426 | N/A | $426 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $400 | N/A | $400 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $320 | N/A | $320 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Oral Hygiene Instructions | $55 | N/A | $55 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $31 | N/A | $31 |
| X-Ray - Complete Intraoral Series | $193 | N/A | $193 |
| X-Ray - Four Images, Bitewings | $93 | N/A | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | N/A | $163 |
