| Dental Cleaning - Adult | $86 | N/A | $86 |
| Dental Cleaning - Child | $70 | N/A | $70 |
| Dental Exam - Periodic, Established Patient | $41 | N/A | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $131 | N/A | $131 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $260 | N/A | $260 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | N/A | $260 |
| Flouride - Topical Varnish Application | $40 | N/A | $40 |
| Fluoride - Topical Application | $35 | N/A | $35 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | N/A | $74 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | N/A | $53 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $40 | N/A | $40 |
| X-Ray - Whole Mouth from Outside Mouth | $116 | N/A | $116 |
