| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
