| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $183 | N/A | $183 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $250 | N/A | $250 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | N/A | $308 |
| Dental Filling - White (Resin): One Surface, Anterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): One Surface, Posterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $375 | N/A | $375 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $295 | N/A | $295 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | N/A | $308 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | N/A | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | N/A | $216 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $159 | N/A | $159 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
