| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | N/A | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | N/A | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | N/A | $286 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $99 | N/A | $99 |
| Root Canal - Anterior Tooth | $877 | N/A | $877 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $207 | N/A | $207 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | N/A | $129 |
