| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $140 | N/A | $140 |
| Dental Exam - Comprehensive | $121 | N/A | $121 |
| Dental Exam - Periodic, Established Patient | $71 | N/A | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $235 | N/A | $235 |
| Flouride - Topical Varnish Application | $71 | N/A | $71 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $352 | N/A | $352 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | N/A | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | N/A | $41 |
| X-Ray - Complete Intraoral Series | $194 | N/A | $194 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | N/A | $60 |
