| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $208 | N/A | $208 |
| Dental Exam - Periodic, Established Patient | $72 | N/A | $72 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $473 | N/A | $473 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $476 | N/A | $476 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $527 | N/A | $527 |
| Fluoride - Topical Application | $56 | N/A | $56 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
