| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $196 | N/A | $196 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | N/A | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $182 | N/A | $182 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| 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 | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $187 | N/A | $187 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
