| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $126 | N/A | $126 |
| Dental Exam - Comprehensive | $184 | N/A | $184 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $368 | N/A | $368 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $386 | N/A | $386 |
| Dental Filling - White (Resin): One Surface, Anterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): One Surface, Posterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $368 | N/A | $368 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | N/A | $368 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $152 | N/A | $152 |
| Root Canal - Bicuspid Tooth | $1,449 | N/A | $1,449 |
| Root Canal - Molar | $2,835 | N/A | $2,835 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Whole Mouth from Outside Mouth | $205 | N/A | $205 |
