| Dental Cleaning - Adult | $99 | N/A | $99 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $111 | N/A | $111 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $156 | N/A | $156 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $201 | N/A | $201 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | N/A | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $277 | N/A | $277 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $230 | N/A | $230 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $227 | N/A | $227 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Fluoride - Topical Application | $40 | N/A | $40 |
| Maintenance Therapy - Periodontal | $143 | N/A | $143 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | N/A | $82 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | N/A | $62 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $144 | N/A | $144 |
| X-Ray - Four Images, Bitewings | $90 | N/A | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | N/A | $121 |
