| Dental Cleaning - Adult | $145 | N/A | $145 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | N/A | $166 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | N/A | $252 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Tooth Extraction - Elevation and/or Forceps Removal | $179 | N/A | $179 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
