| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $129 | N/A | $129 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | N/A | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $323 | N/A | $323 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $275 | N/A | $275 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $323 | N/A | $323 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | N/A | $234 |
| Flouride - Topical Varnish Application | $97 | N/A | $97 |
| Maintenance Therapy - Periodontal | $163 | N/A | $163 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $305 | N/A | $305 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $107 | N/A | $107 |
