| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $361 | N/A | $361 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $523 | N/A | $523 |
| Dental Filling - White (Resin): One Surface, Anterior | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Posterior | $361 | N/A | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $230 | N/A | $230 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $523 | N/A | $523 |
| Flouride - Topical Varnish Application | $60 | N/A | $60 |
| Fluoride - Topical Application | $60 | N/A | $60 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $120 | N/A | $120 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $91 | N/A | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
