| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $124 | N/A | $124 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $431 | N/A | $431 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $431 | N/A | $431 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Oral Hygiene Instructions | $58 | N/A | $58 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | N/A | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $112 | N/A | $112 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | N/A | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | N/A | $47 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
