| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $99 | N/A | $99 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| 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 | $182 | N/A | $182 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $162 | N/A | $162 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Tooth Extraction - Elevation and/or Forceps Removal | $243 | N/A | $243 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
