| Dental Cleaning - Adult | $168 | N/A | $168 |
| Dental Cleaning - Child | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | N/A | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $289 | N/A | $289 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $357 | N/A | $357 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | N/A | $323 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $294 | N/A | $294 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Molar | $2,730 | N/A | $2,730 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
