| Dental Cleaning - Adult | $95 | N/A | $95 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $158 | N/A | $158 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | N/A | $158 |
| Flouride - Topical Varnish Application | $74 | N/A | $74 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | N/A | $84 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $139 | N/A | $139 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | N/A | $121 |
