| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | N/A | $404 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $341 | N/A | $341 |
| Dental Filling - White (Resin): One Surface, Anterior | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Posterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $490 | N/A | $490 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $341 | N/A | $341 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | N/A | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | N/A | $184 |
