| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $112 | N/A | $112 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $153 | N/A | $153 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $230 | N/A | $230 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | N/A | $191 |
| Dental Filling - White (Resin): One Surface, Posterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $231 | N/A | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | N/A | $72 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | N/A | $41 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
