| Dental Cleaning - Adult | $135 | N/A | $135 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $130 | N/A | $130 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $470 | N/A | $470 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - White (Resin): One Surface, Anterior | $232 | N/A | $232 |
| Dental Filling - White (Resin): One Surface, Posterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $470 | N/A | $470 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $319 | N/A | $319 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $347 | N/A | $347 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $189 | N/A | $189 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | N/A | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $151 | N/A | $151 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | N/A | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $249 | N/A | $249 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $206 | N/A | $206 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $206 | N/A | $206 |
