| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $116 | N/A | $116 |
| Dental Exam - Comprehensive | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $89 | N/A | $89 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $297 | N/A | $297 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | N/A | $191 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $211 | N/A | $211 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $253 | N/A | $253 |
| Fluoride - Topical Application | $85 | N/A | $85 |
| Maintenance Therapy - Periodontal | $183 | N/A | $183 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | N/A | $89 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | N/A | $63 |
| X-Ray - Complete Intraoral Series | $180 | N/A | $180 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $68 | N/A | $68 |
| X-Ray - Two Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
