| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $258 | N/A | $258 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $149 | N/A | $149 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
