| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | N/A | $173 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $158 | N/A | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $214 | N/A | $214 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $424 | N/A | $424 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Flouride - Topical Varnish Application | $79 | N/A | $79 |
| Fluoride - Topical Application | $63 | N/A | $63 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | N/A | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $74 | N/A | $74 |
