| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $182 | N/A | $182 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $40 | N/A | $40 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $200 | N/A | $200 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | N/A | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $123 | N/A | $123 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | N/A | $62 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $224 | N/A | $224 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $175 | N/A | $175 |
