| Dental Cleaning - Adult | $164 | N/A | $164 |
| Dental Exam - Periodic, Established Patient | $92 | N/A | $92 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | N/A | $166 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $240 | N/A | $240 |
| Dental Filling - White (Resin): One Surface, Anterior | $309 | N/A | $309 |
| Dental Filling - White (Resin): One Surface, Posterior | $332 | N/A | $332 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $578 | N/A | $578 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $384 | N/A | $384 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $481 | N/A | $481 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $176 | N/A | $176 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
