| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $75 | N/A | $75 |
| Dental Exam - Comprehensive | $147 | N/A | $147 |
| Dental Exam - Periodic, Established Patient | $43 | N/A | $43 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | N/A | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | N/A | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | N/A | $173 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | N/A | $236 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $57 | N/A | $57 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
| X-Ray - Whole Mouth from Outside Mouth | $128 | N/A | $128 |
