| Dental Cleaning - Adult | $135 | N/A | $135 |
| Dental Cleaning - Child | $108 | N/A | $108 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | N/A | $331 |
| Dental Filling - White (Resin): One Surface, Anterior | $297 | N/A | $297 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $523 | N/A | $523 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | N/A | $331 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $192 | N/A | $192 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Root Canal - Bicuspid Tooth | $1,328 | N/A | $1,328 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $186 | N/A | $186 |
| X-Ray - Four Images, Bitewings | $91 | N/A | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
