| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $172 | N/A | $172 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $337 | N/A | $337 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Root Canal - Molar | $1,482 | N/A | $1,482 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | N/A | $218 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $214 | N/A | $214 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
