| Dental Cleaning - Adult | $155 | N/A | $155 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $319 | N/A | $319 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $53 | N/A | $53 |
| Oral Hygiene Instructions | $22 | N/A | $22 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $224 | N/A | $224 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $190 | N/A | $190 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $134 | N/A | $134 |
