| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $391 | N/A | $391 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $307 | N/A | $307 |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | N/A | $307 |
| Flouride - Topical Varnish Application | $40 | N/A | $40 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Oral Hygiene Instructions | $37 | N/A | $37 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | N/A | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $352 | N/A | $352 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $171 | N/A | $171 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
