| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $438 | N/A | $438 |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | N/A | $278 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $341 | N/A | $341 |
| Flouride - Topical Varnish Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| X-Ray - Complete Intraoral Series | $194 | N/A | $194 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
