| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $43 | N/A | $43 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $269 | N/A | $269 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $368 | N/A | $368 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - White (Resin): One Surface, Anterior | $172 | N/A | $172 |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $360 | N/A | $360 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $468 | N/A | $468 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $383 | N/A | $383 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | N/A | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $218 | N/A | $218 |
| X-Ray - Four Images, Bitewings | $73 | N/A | $73 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Whole Mouth from Outside Mouth | $110 | N/A | $110 |
