| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $305 | N/A | $305 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | N/A | $252 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | N/A | $276 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $145 | N/A | $145 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
