| Dental Cleaning - Adult | $139 | N/A | $139 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $210 | N/A | $210 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $336 | N/A | $336 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $417 | N/A | $417 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $389 | N/A | $389 |
| Dental Filling - White (Resin): One Surface, Posterior | $336 | N/A | $336 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | N/A | $417 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | N/A | $389 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $284 | N/A | $284 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $394 | N/A | $394 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | N/A | $137 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $374 | N/A | $374 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $170 | N/A | $170 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | N/A | $170 |
