| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $300 | N/A | $300 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Oral Hygiene Instructions | $59 | N/A | $59 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | N/A | $278 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | N/A | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $185 | N/A | $185 |
