| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $80 | N/A | $80 |
| Dental Exam - Comprehensive | $138 | N/A | $138 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $193 | N/A | $193 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $371 | N/A | $371 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | N/A | $230 |
| Dental Filling - White (Resin): One Surface, Anterior | $340 | N/A | $340 |
| Dental Filling - White (Resin): One Surface, Posterior | $193 | N/A | $193 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $371 | N/A | $371 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $432 | N/A | $432 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $117 | N/A | $117 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | N/A | $75 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | N/A | $25 |
| X-Ray - Complete Intraoral Series | $192 | N/A | $192 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | N/A | $170 |
