| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $180 | N/A | $180 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | N/A | $281 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $248 | N/A | $248 |
| Dental Filling - White (Resin): One Surface, Anterior | $178 | N/A | $178 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | N/A | $281 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $248 | N/A | $248 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $287 | N/A | $287 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | N/A | $85 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | N/A | $188 |
| X-Ray - Complete Intraoral Series | $218 | N/A | $218 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
| X-Ray - Whole Mouth from Outside Mouth | $146 | N/A | $146 |
