| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| 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 | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Bicuspid Tooth | $979 | N/A | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
