| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $79 | N/A | $79 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | N/A | $410 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | N/A | $84 |
| Root Canal - Anterior Tooth | $761 | N/A | $761 |
| Root Canal - Bicuspid Tooth | $935 | N/A | $935 |
| Root Canal - Molar | $1,443 | N/A | $1,443 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | N/A | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | N/A | $22 |
| X-Ray - Complete Intraoral Series | $204 | N/A | $204 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
