| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $147 | N/A | $147 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $320 | N/A | $320 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | N/A | $289 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | N/A | $315 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Maintenance Therapy - Periodontal | $163 | N/A | $163 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | N/A | $126 |
| Root Canal - Bicuspid Tooth | $1,155 | N/A | $1,155 |
| Root Canal - Molar | $1,355 | N/A | $1,355 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | N/A | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $242 | N/A | $242 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | N/A | $152 |
