| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $117 | N/A | $117 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $204 | N/A | $204 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | N/A | $345 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $288 | N/A | $288 |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | N/A | $345 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $279 | N/A | $279 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | N/A | $288 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Maintenance Therapy - Periodontal | $319 | N/A | $319 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Root Canal - Molar | $1,329 | N/A | $1,329 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | N/A | $240 |
| X-Ray - Complete Intraoral Series | $204 | N/A | $204 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | N/A | $170 |
