| Dental Cleaning - Adult | $155 | N/A | $155 |
| Dental Cleaning - Child | $106 | N/A | $106 |
| Dental Exam - Comprehensive | $109 | N/A | $109 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $204 | N/A | $204 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | N/A | $348 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | N/A | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $255 | N/A | $255 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | N/A | $276 |
| Fluoride - Topical Application | $65 | N/A | $65 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $148 | N/A | $148 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | N/A | $45 |
| X-Ray - Complete Intraoral Series | $174 | N/A | $174 |
| X-Ray - Four Images, Bitewings | $90 | N/A | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
