| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $195 | N/A | $195 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | N/A | $281 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | N/A | $389 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | N/A | $306 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $164 | N/A | $164 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
