| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $127 | N/A | $127 |
| Dental Exam - Comprehensive | $137 | N/A | $137 |
| Dental Exam - Periodic, Established Patient | $45 | N/A | $45 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $683 | N/A | $683 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $499 | N/A | $499 |
| Dental Filling - White (Resin): One Surface, Anterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $551 | N/A | $551 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $473 | N/A | $473 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | N/A | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | N/A | $21 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $22 | N/A | $22 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | N/A | $152 |
