| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $113 | N/A | $113 |
| Dental Exam - Comprehensive | $121 | N/A | $121 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $382 | N/A | $382 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $303 | N/A | $303 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $382 | N/A | $382 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $244 | N/A | $244 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | N/A | $303 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $183 | N/A | $183 |
| Oral Hygiene Instructions | $62 | N/A | $62 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | N/A | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | N/A | $109 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $196 | N/A | $196 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | N/A | $42 |
| X-Ray - Complete Intraoral Series | $164 | N/A | $164 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | N/A | $149 |
