| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $125 | N/A | $125 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $271 | N/A | $271 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $396 | N/A | $396 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $323 | N/A | $323 |
| Dental Filling - White (Resin): One Surface, Anterior | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Posterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $396 | N/A | $396 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $288 | N/A | $288 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | N/A | $323 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $359 | N/A | $359 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | N/A | $111 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $277 | N/A | $277 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $212 | N/A | $212 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | N/A | $161 |
