| Dental Cleaning - Adult | $158 | N/A | $158 |
| Dental Cleaning - Child | $76 | N/A | $76 |
| Dental Exam - Comprehensive | $141 | N/A | $141 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $163 | N/A | $163 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $271 | N/A | $271 |
| Dental Filling - White (Resin): One Surface, Posterior | $286 | N/A | $286 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $443 | N/A | $443 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | N/A | $368 |
| Flouride - Topical Varnish Application | $82 | N/A | $82 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $194 | N/A | $194 |
| X-Ray - Four Images, Bitewings | $111 | N/A | $111 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
