| Dental Cleaning - Adult | $98 | N/A | $98 |
| Dental Cleaning - Child | $78 | N/A | $78 |
| Dental Exam - Comprehensive | $83 | N/A | $83 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | N/A | $166 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $301 | N/A | $301 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $148 | N/A | $148 |
| Dental Filling - White (Resin): One Surface, Posterior | $166 | N/A | $166 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $301 | N/A | $301 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $181 | N/A | $181 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $144 | N/A | $144 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | N/A | $254 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | N/A | $80 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | N/A | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $172 | N/A | $172 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | N/A | $25 |
| X-Ray - Complete Intraoral Series | $140 | N/A | $140 |
| X-Ray - Four Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $144 | N/A | $144 |
