| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | N/A | $394 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | N/A | $394 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | N/A | $315 |
| Flouride - Topical Varnish Application | $68 | N/A | $68 |
| Maintenance Therapy - Periodontal | $189 | N/A | $189 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $205 | N/A | $205 |
| X-Ray - Four Images, Bitewings | $110 | N/A | $110 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
