| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $353 | N/A | $353 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | N/A | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $347 | N/A | $347 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $153 | N/A | $153 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
