| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | N/A | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | N/A | $373 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | N/A | $294 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| X-Ray - Complete Intraoral Series | $223 | N/A | $223 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
