| Dental Cleaning - Adult | $90 | N/A | $90 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $79 | N/A | $79 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | N/A | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | N/A | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | N/A | $268 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $235 | N/A | $235 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $76 | N/A | $76 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | N/A | $49 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $126 | N/A | $126 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
