| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $179 | N/A | $179 |
| Dental Exam - Comprehensive | $142 | N/A | $142 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $425 | N/A | $425 |
| Flouride - Topical Varnish Application | $97 | N/A | $97 |
| Maintenance Therapy - Periodontal | $162 | N/A | $162 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $893 | N/A | $893 |
| Root Canal - Bicuspid Tooth | $2,510 | N/A | $2,510 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Complete Intraoral Series | $227 | N/A | $227 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $116 | N/A | $116 |
