| Dental Cleaning - Adult | $144 | N/A | $144 |
| Dental Cleaning - Child | $106 | N/A | $106 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $252 | N/A | $252 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $349 | N/A | $349 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $416 | N/A | $416 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $274 | N/A | $274 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $352 | N/A | $352 |
| Fluoride - Topical Application | $59 | N/A | $59 |
| Maintenance Therapy - Periodontal | $185 | N/A | $185 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $333 | N/A | $333 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | N/A | $111 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | N/A | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $447 | N/A | $447 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | N/A | $45 |
| X-Ray - Complete Intraoral Series | $193 | N/A | $193 |
| X-Ray - Four Images, Bitewings | $93 | N/A | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | N/A | $163 |
