| Dental Cleaning - Adult | $163 | N/A | $163 |
| Dental Cleaning - Child | $131 | N/A | $131 |
| Dental Exam - Comprehensive | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $247 | N/A | $247 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $375 | N/A | $375 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): One Surface, Posterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | N/A | $368 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Maintenance Therapy - Periodontal | $205 | N/A | $205 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $140 | N/A | $140 |
| Tooth Extraction - Elevation and/or Forceps Removal | $310 | N/A | $310 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | N/A | $47 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $100 | N/A | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $58 | N/A | $58 |
