| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | N/A | $191 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | N/A | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | N/A | $265 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $155 | N/A | $155 |
| Oral Hygiene Instructions | $46 | N/A | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $150 | N/A | $150 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
