| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $235 | N/A | $235 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $381 | N/A | $381 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $299 | N/A | $299 |
| Dental Filling - White (Resin): One Surface, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $381 | N/A | $381 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | N/A | $299 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Maintenance Therapy - Periodontal | $182 | N/A | $182 |
| Oral Hygiene Instructions | $58 | N/A | $58 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $335 | N/A | $335 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | N/A | $72 |
| Tooth Extraction - Elevation and/or Forceps Removal | $235 | N/A | $235 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $151 | N/A | $151 |
