| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $64 | N/A | $64 |
| Maintenance Therapy - Periodontal | $204 | N/A | $204 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $319 | N/A | $319 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| X-Ray - Complete Intraoral Series | $224 | N/A | $224 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
