| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $79 | N/A | $79 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | N/A | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $341 | N/A | $341 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | N/A | $410 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | N/A | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Molar | $1,496 | N/A | $1,496 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $100 | N/A | $100 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $173 | N/A | $173 |
