| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $45 | N/A | $45 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $269 | N/A | $269 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $182 | N/A | $182 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $296 | N/A | $296 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $217 | N/A | $217 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $254 | N/A | $254 |
| Fluoride - Topical Application | $38 | N/A | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | N/A | $22 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $45 | N/A | $45 |
