| Dental Cleaning - Adult | $153 | N/A | $153 |
| Dental Cleaning - Child | $124 | N/A | $124 |
| Dental Exam - Comprehensive | $169 | N/A | $169 |
| Dental Exam - Periodic, Established Patient | $71 | N/A | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $271 | N/A | $271 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $515 | N/A | $515 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $412 | N/A | $412 |
| Dental Filling - White (Resin): One Surface, Anterior | $258 | N/A | $258 |
| Dental Filling - White (Resin): One Surface, Posterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $540 | N/A | $540 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $412 | N/A | $412 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $412 | N/A | $412 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $379 | N/A | $379 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | N/A | $108 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | N/A | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $278 | N/A | $278 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $230 | N/A | $230 |
| X-Ray - Four Images, Bitewings | $99 | N/A | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | N/A | $60 |
| X-Ray - Two Images, Bitewings | $96 | N/A | $96 |
| X-Ray - Whole Mouth from Outside Mouth | $188 | N/A | $188 |
