| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $167 | N/A | $167 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | N/A | $315 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Fluoride - Topical Application | $84 | N/A | $84 |
| Maintenance Therapy - Periodontal | $142 | N/A | $142 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | N/A | $79 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | N/A | $55 |
| Tooth Extraction - Elevation and/or Forceps Removal | $179 | N/A | $179 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $173 | N/A | $173 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
