| Dental Cleaning - Adult | $151 | N/A | $151 |
| Dental Cleaning - Child | $119 | N/A | $119 |
| Dental Exam - Comprehensive | $144 | N/A | $144 |
| Dental Exam - Periodic, Established Patient | $91 | N/A | $91 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $431 | N/A | $431 |
| Dental Filling - White (Resin): One Surface, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Posterior | $303 | N/A | $303 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $418 | N/A | $418 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $355 | N/A | $355 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $221 | N/A | $221 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $398 | N/A | $398 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $139 | N/A | $139 |
| X-Ray - Complete Intraoral Series | $230 | N/A | $230 |
| X-Ray - Four Images, Bitewings | $104 | N/A | $104 |
| X-Ray - Intraoral, Periapical Radiographic Image | $51 | N/A | $51 |
| X-Ray - Two Images, Bitewings | $101 | N/A | $101 |
| X-Ray - Whole Mouth from Outside Mouth | $193 | N/A | $193 |
