| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | N/A | $247 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $203 | N/A | $203 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | N/A | $25 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
