| Dental Cleaning - Adult | $90 | N/A | $90 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $197 | N/A | $197 |
| Dental Filling - White (Resin): One Surface, Anterior | $161 | N/A | $161 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | N/A | $215 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $34 | N/A | $34 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $76 | N/A | $76 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | N/A | $49 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $132 | N/A | $132 |
| X-Ray - Four Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $46 | N/A | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $118 | N/A | $118 |
