| Dental Cleaning - Adult | $158 | N/A | $158 |
| Dental Cleaning - Child | $137 | N/A | $137 |
| Dental Exam - Comprehensive | $158 | N/A | $158 |
| Dental Exam - Periodic, Established Patient | $95 | N/A | $95 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $420 | N/A | $420 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | N/A | $368 |
| Fluoride - Topical Application | $63 | N/A | $63 |
| Maintenance Therapy - Periodontal | $210 | N/A | $210 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | N/A | $131 |
| Root Canal - Molar | $1,890 | N/A | $1,890 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $242 | N/A | $242 |
| X-Ray - Four Images, Bitewings | $137 | N/A | $137 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Whole Mouth from Outside Mouth | $200 | N/A | $200 |
