| Dental Cleaning - Adult | $113 | N/A | $113 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | N/A | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | N/A | $268 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Oral Hygiene Instructions | $53 | N/A | $53 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Root Canal - Anterior Tooth | $1,323 | N/A | $1,323 |
| Root Canal - Bicuspid Tooth | $1,208 | N/A | $1,208 |
| Root Canal - Molar | $1,444 | N/A | $1,444 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | N/A | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
