| Dental Cleaning - Adult | $168 | N/A | $168 |
| Dental Cleaning - Child | $63 | N/A | $63 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | N/A | $336 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $336 | N/A | $336 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | N/A | $68 |
| 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 | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $128 | N/A | $128 |
| X-Ray - Four Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $39 | N/A | $39 |
