| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $78 | N/A | $78 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | N/A | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $252 | N/A | $252 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Anterior | $166 | N/A | $166 |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | N/A | $215 |
| Flouride - Topical Varnish Application | $65 | N/A | $65 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $230 | N/A | $230 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $145 | N/A | $145 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
