| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $357 | N/A | $357 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | N/A | $315 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | N/A | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | N/A | $47 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $137 | N/A | $137 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
