| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $111 | N/A | $111 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $378 | N/A | $378 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| 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 | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $234 | N/A | $234 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Root Canal - Bicuspid Tooth | $1,050 | N/A | $1,050 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | N/A | $72 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | N/A | $41 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
