| Dental Cleaning - Adult | $117 | N/A | $117 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | N/A | $354 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $293 | N/A | $293 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | N/A | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | N/A | $293 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $159 | N/A | $159 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | N/A | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $123 | N/A | $123 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $185 | N/A | $185 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | N/A | $149 |
