| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $98 | N/A | $98 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | N/A | $211 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $324 | N/A | $324 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | N/A | $211 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $324 | N/A | $324 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Fluoride - Topical Application | $39 | N/A | $39 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Root Canal - Molar | $1,103 | N/A | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | N/A | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Complete Intraoral Series | $161 | N/A | $161 |
| X-Ray - Four Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
