| Dental Cleaning - Adult | $90 | N/A | $90 |
| Dental Cleaning - Child | $63 | N/A | $63 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $244 | N/A | $244 |
| Flouride - Topical Varnish Application | $36 | N/A | $36 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | N/A | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $50 | N/A | $50 |
| X-Ray - Complete Intraoral Series | $132 | N/A | $132 |
| X-Ray - Four Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
