| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $145 | N/A | $145 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $182 | N/A | $182 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $151 | N/A | $151 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
