| Dental Cleaning - Adult | $115 | N/A | $115 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $429 | N/A | $429 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - White (Resin): One Surface, Posterior | $230 | N/A | $230 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $330 | N/A | $330 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $418 | N/A | $418 |
| Flouride - Topical Varnish Application | $52 | N/A | $52 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $150 | N/A | $150 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $46 | N/A | $46 |
| X-Ray - Complete Intraoral Series | $178 | N/A | $178 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | N/A | $71 |
| X-Ray - Two Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $186 | N/A | $186 |
