| Dental Cleaning - Adult | $113 | N/A | $113 |
| Dental Cleaning - Child | $99 | N/A | $99 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $421 | N/A | $421 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | N/A | $173 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $421 | N/A | $421 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $159 | N/A | $159 |
| Oral Hygiene Instructions | $60 | N/A | $60 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | N/A | $318 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $156 | N/A | $156 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
