| Dental Cleaning - Adult | $134 | N/A | $134 |
| Dental Cleaning - Child | $98 | N/A | $98 |
| Dental Exam - Comprehensive | $113 | N/A | $113 |
| Dental Exam - Periodic, Established Patient | $72 | N/A | $72 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | N/A | $249 |
| Dental Filling - White (Resin): One Surface, Anterior | $238 | N/A | $238 |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | N/A | $249 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $385 | N/A | $385 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | N/A | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Fluoride - Topical Application | $56 | N/A | $56 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $238 | N/A | $238 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
