| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $70 | N/A | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | N/A | $226 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $274 | N/A | $274 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | N/A | $289 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $175 | N/A | $175 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Root Canal - Anterior Tooth | $1,024 | N/A | $1,024 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $176 | N/A | $176 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
