| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $124 | N/A | $124 |
| Dental Exam - Periodic, Established Patient | $70 | N/A | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $395 | N/A | $395 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $319 | N/A | $319 |
| Dental Filling - White (Resin): One Surface, Anterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): One Surface, Posterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | N/A | $395 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $277 | N/A | $277 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $319 | N/A | $319 |
| Flouride - Topical Varnish Application | $59 | N/A | $59 |
| Maintenance Therapy - Periodontal | $190 | N/A | $190 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $344 | N/A | $344 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | N/A | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $259 | N/A | $259 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $176 | N/A | $176 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | N/A | $169 |
