| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $306 | N/A | $306 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | N/A | $417 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | N/A | $303 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $203 | N/A | $203 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $620 | N/A | $620 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | N/A | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $181 | N/A | $181 |
| X-Ray - Four Images, Bitewings | $100 | N/A | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | N/A | $182 |
