| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $331 | N/A | $331 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | N/A | $245 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $274 | N/A | $274 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Root Canal - Bicuspid Tooth | $1,238 | N/A | $1,238 |
| Root Canal - Molar | $1,758 | N/A | $1,758 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $114 | N/A | $114 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | N/A | $170 |
