| Dental Cleaning - Adult | $144 | N/A | $144 |
| Dental Exam - Comprehensive | $133 | N/A | $133 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $343 | N/A | $343 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $448 | N/A | $448 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $406 | N/A | $406 |
| Dental Filling - White (Resin): One Surface, Anterior | $280 | N/A | $280 |
| Dental Filling - White (Resin): One Surface, Posterior | $343 | N/A | $343 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $448 | N/A | $448 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $343 | N/A | $343 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $406 | N/A | $406 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $347 | N/A | $347 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $305 | N/A | $305 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| Tooth Extraction - Elevation and/or Forceps Removal | $364 | N/A | $364 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $169 | N/A | $169 |
| X-Ray - Four Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $197 | N/A | $197 |
