| Dental Cleaning - Adult | $144 | N/A | $144 |
| Dental Cleaning - Child | $81 | N/A | $81 |
| Dental Exam - Comprehensive | $168 | N/A | $168 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $303 | N/A | $303 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $469 | N/A | $469 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $396 | N/A | $396 |
| Dental Filling - White (Resin): One Surface, Anterior | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Posterior | $307 | N/A | $307 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | N/A | $460 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $307 | N/A | $307 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $396 | N/A | $396 |
| Flouride - Topical Varnish Application | $70 | N/A | $70 |
| Maintenance Therapy - Periodontal | $225 | N/A | $225 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | N/A | $121 |
| Root Canal - Anterior Tooth | $1,236 | N/A | $1,236 |
| Root Canal - Molar | $1,544 | N/A | $1,544 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $313 | N/A | $313 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $194 | N/A | $194 |
| X-Ray - Four Images, Bitewings | $102 | N/A | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
