| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | N/A | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $320 | N/A | $320 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | N/A | $55 |
| Tooth Extraction - Elevation and/or Forceps Removal | $181 | N/A | $181 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $203 | N/A | $203 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $48 | N/A | $48 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | N/A | $127 |
