| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Anterior | $195 | N/A | $195 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $210 | N/A | $210 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $142 | N/A | $142 |
| 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 | $107 | N/A | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
