| Dental Cleaning - Adult | $90 | N/A | $90 |
| Dental Cleaning - Child | $111 | N/A | $111 |
| Dental Exam - Comprehensive | $168 | N/A | $168 |
| Dental Exam - Periodic, Established Patient | $67 | N/A | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $280 | N/A | $280 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Anterior | $138 | N/A | $138 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $280 | N/A | $280 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $169 | N/A | $169 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | N/A | $215 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $151 | N/A | $151 |
| Tooth Extraction - Elevation and/or Forceps Removal | $399 | N/A | $399 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $132 | N/A | $132 |
| X-Ray - Four Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $46 | N/A | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | N/A | $165 |
