| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | N/A | $276 |
| Dental Filling - White (Resin): One Surface, Anterior | $166 | N/A | $166 |
| Dental Filling - White (Resin): One Surface, Posterior | $190 | N/A | $190 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $264 | N/A | $264 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $149 | N/A | $149 |
| Oral Hygiene Instructions | $45 | N/A | $45 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | N/A | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
