| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $99 | N/A | $99 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | N/A | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $251 | N/A | $251 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | N/A | $362 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | N/A | $286 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $162 | N/A | $162 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | N/A | $288 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
