| Dental Cleaning - Adult | $97 | N/A | $97 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | N/A | $276 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | N/A | $183 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $146 | N/A | $146 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $44 | N/A | $44 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | N/A | $129 |
