| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | N/A | $372 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | N/A | $299 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | N/A | $137 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $192 | N/A | $192 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $144 | N/A | $144 |
