| Dental Cleaning - Adult | $130 | N/A | $130 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $163 | N/A | $163 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $328 | N/A | $328 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $520 | N/A | $520 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $425 | N/A | $425 |
| Dental Filling - White (Resin): One Surface, Anterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): One Surface, Posterior | $320 | N/A | $320 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $509 | N/A | $509 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $389 | N/A | $389 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $425 | N/A | $425 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $165 | N/A | $165 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $160 | N/A | $160 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
