| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | N/A | $348 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $445 | N/A | $445 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $258 | N/A | $258 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | N/A | $298 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $169 | N/A | $169 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | N/A | $41 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
