| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $239 | N/A | $239 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | N/A | $378 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | N/A | $307 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | N/A | $63 |
| X-Ray - Complete Intraoral Series | $173 | N/A | $173 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
