| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $77 | N/A | $77 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | N/A | $273 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Complete Intraoral Series | $137 | N/A | $137 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | N/A | $30 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
