| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $113 | N/A | $113 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $274 | N/A | $274 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $234 | N/A | $234 |
| Dental Filling - White (Resin): One Surface, Anterior | $214 | N/A | $214 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $382 | N/A | $382 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | N/A | $261 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $318 | N/A | $318 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $158 | N/A | $158 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | N/A | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | N/A | $182 |
