| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | N/A | $318 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | N/A | $260 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | N/A | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | N/A | $260 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $145 | N/A | $145 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | N/A | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | N/A | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | N/A | $23 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $172 | N/A | $172 |
