| Dental Cleaning - Adult | $155 | N/A | $155 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | N/A | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $303 | N/A | $303 |
| Dental Filling - White (Resin): One Surface, Anterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | N/A | $460 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $239 | N/A | $239 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $335 | N/A | $335 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | N/A | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $218 | N/A | $218 |
| X-Ray - Four Images, Bitewings | $102 | N/A | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | N/A | $156 |
