| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | N/A | $334 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | N/A | $348 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $146 | N/A | $146 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | N/A | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | N/A | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | N/A | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
