| Dental Cleaning - Adult | $145 | N/A | $145 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $107 | N/A | $107 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| X-Ray - Complete Intraoral Series | $198 | N/A | $198 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
