| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | N/A | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | N/A | $310 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | N/A | $205 |
| Fluoride - Topical Application | $53 | N/A | $53 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | N/A | $168 |
| X-Ray - Complete Intraoral Series | $144 | N/A | $144 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
