| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $408 | N/A | $408 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | N/A | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | N/A | $408 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | N/A | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $437 | N/A | $437 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $193 | N/A | $193 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
