| Dental Cleaning - Adult | $141 | N/A | $141 |
| Dental Cleaning - Child | $119 | N/A | $119 |
| Dental Exam - Comprehensive | $137 | N/A | $137 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $287 | N/A | $287 |
| Dental Filling - White (Resin): One Surface, Posterior | $287 | N/A | $287 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | N/A | $395 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $340 | N/A | $340 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | N/A | $43 |
| X-Ray - Two Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
