| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $389 | N/A | $389 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $465 | N/A | $465 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Anterior Tooth | $893 | N/A | $893 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
