| Dental Cleaning - Adult | $167 | N/A | $167 |
| Dental Cleaning - Child | $122 | N/A | $122 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $306 | N/A | $306 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $439 | N/A | $439 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $381 | N/A | $381 |
| Dental Filling - White (Resin): One Surface, Anterior | $260 | N/A | $260 |
| Dental Filling - White (Resin): One Surface, Posterior | $306 | N/A | $306 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $439 | N/A | $439 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $381 | N/A | $381 |
| Maintenance Therapy - Periodontal | $187 | N/A | $187 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $444 | N/A | $444 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $134 | N/A | $134 |
| Tooth Extraction - Elevation and/or Forceps Removal | $447 | N/A | $447 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | N/A | $45 |
| X-Ray - Complete Intraoral Series | $334 | N/A | $334 |
| X-Ray - Four Images, Bitewings | $106 | N/A | $106 |
| X-Ray - Intraoral, Periapical Radiographic Image | $56 | N/A | $56 |
| X-Ray - Two Images, Bitewings | $87 | N/A | $87 |
| X-Ray - Whole Mouth from Outside Mouth | $223 | N/A | $223 |
