| Dental Cleaning - Adult | $170 | N/A | $170 |
| Dental Cleaning - Child | $132 | N/A | $132 |
| Dental Exam - Comprehensive | $123 | N/A | $123 |
| Dental Exam - Periodic, Established Patient | $86 | N/A | $86 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $408 | N/A | $408 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | N/A | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | N/A | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Flouride - Topical Varnish Application | $74 | N/A | $74 |
| Fluoride - Topical Application | $63 | N/A | $63 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $435 | N/A | $435 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | N/A | $130 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $88 | N/A | $88 |
| Tooth Extraction - Elevation and/or Forceps Removal | $228 | N/A | $228 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $48 | N/A | $48 |
| X-Ray - Complete Intraoral Series | $260 | N/A | $260 |
| X-Ray - Four Images, Bitewings | $109 | N/A | $109 |
| X-Ray - Intraoral, Periapical Radiographic Image | $55 | N/A | $55 |
| X-Ray - Two Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
