| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $168 | N/A | $168 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | N/A | $298 |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $197 | N/A | $197 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $135 | N/A | $135 |
| 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 | $22 | N/A | $22 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | N/A | $121 |
