| Dental Cleaning - Adult | $134 | N/A | $134 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $141 | N/A | $141 |
| Dental Exam - Periodic, Established Patient | $78 | N/A | $78 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $275 | N/A | $275 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $340 | N/A | $340 |
| Dental Filling - White (Resin): One Surface, Anterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): One Surface, Posterior | $275 | N/A | $275 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $416 | N/A | $416 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $295 | N/A | $295 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $340 | N/A | $340 |
| Flouride - Topical Varnish Application | $66 | N/A | $66 |
| Maintenance Therapy - Periodontal | $221 | N/A | $221 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $404 | N/A | $404 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | N/A | $108 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | N/A | $83 |
| Tooth Extraction - Elevation and/or Forceps Removal | $275 | N/A | $275 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $194 | N/A | $194 |
| X-Ray - Four Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $167 | N/A | $167 |
