| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $45 | N/A | $45 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | N/A | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $238 | N/A | $238 |
| Dental Filling - White (Resin): One Surface, Anterior | $152 | N/A | $152 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | N/A | $236 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $197 | N/A | $197 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | N/A | $21 |
| X-Ray - Complete Intraoral Series | $200 | N/A | $200 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $155 | N/A | $155 |
