| Dental Cleaning - Adult | $140 | N/A | $140 |
| Dental Cleaning - Child | $112 | N/A | $112 |
| Dental Exam - Comprehensive | $146 | N/A | $146 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $322 | N/A | $322 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $254 | N/A | $254 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $422 | N/A | $422 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $288 | N/A | $288 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $172 | N/A | $172 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $91 | N/A | $91 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | N/A | $43 |
| X-Ray - Complete Intraoral Series | $209 | N/A | $209 |
| X-Ray - Four Images, Bitewings | $103 | N/A | $103 |
| X-Ray - Intraoral, Periapical Radiographic Image | $54 | N/A | $54 |
