| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $106 | N/A | $106 |
| Dental Exam - Comprehensive | $167 | N/A | $167 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $324 | N/A | $324 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $463 | N/A | $463 |
| Dental Filling - White (Resin): One Surface, Anterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $463 | N/A | $463 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | N/A | $259 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | N/A | $218 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $174 | N/A | $174 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | N/A | $156 |
