| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $172 | N/A | $172 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | N/A | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | N/A | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $65 | N/A | $65 |
| Maintenance Therapy - Periodontal | $328 | N/A | $328 |
| Oral Hygiene Instructions | $55 | N/A | $55 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Whole Mouth from Outside Mouth | $197 | N/A | $197 |
