| Dental Cleaning - Adult | $163 | N/A | $163 |
| Dental Cleaning - Child | $126 | N/A | $126 |
| Dental Exam - Comprehensive | $184 | N/A | $184 |
| Dental Exam - Periodic, Established Patient | $84 | N/A | $84 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $368 | N/A | $368 |
| Dental Filling - White (Resin): One Surface, Anterior | $326 | N/A | $326 |
| Dental Filling - White (Resin): One Surface, Posterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $368 | N/A | $368 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | N/A | $368 |
| Flouride - Topical Varnish Application | $84 | N/A | $84 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $378 | N/A | $378 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $147 | N/A | $147 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | N/A | $89 |
| X-Ray - Complete Intraoral Series | $231 | N/A | $231 |
| X-Ray - Four Images, Bitewings | $126 | N/A | $126 |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | N/A | $53 |
| X-Ray - Two Images, Bitewings | $84 | N/A | $84 |
