| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | N/A | $173 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $433 | N/A | $433 |
| Flouride - Topical Varnish Application | $32 | N/A | $32 |
| Maintenance Therapy - Periodontal | $158 | N/A | $158 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | N/A | $63 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Complete Intraoral Series | $137 | N/A | $137 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Two Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
