| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $368 | N/A | $368 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | N/A | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | N/A | $368 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | N/A | $268 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | N/A | $278 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
