| Dental Cleaning - Adult | $133 | N/A | $133 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $76 | N/A | $76 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $379 | N/A | $379 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $312 | N/A | $312 |
| Dental Filling - White (Resin): One Surface, Anterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): One Surface, Posterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $379 | N/A | $379 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $276 | N/A | $276 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | N/A | $312 |
| Flouride - Topical Varnish Application | $77 | N/A | $77 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Oral Hygiene Instructions | $70 | N/A | $70 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $340 | N/A | $340 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | N/A | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | N/A | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
