| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $71 | N/A | $71 |
| Dental Exam - Comprehensive | $158 | N/A | $158 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | N/A | $191 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | N/A | $252 |
| Flouride - Topical Varnish Application | $32 | N/A | $32 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | N/A | $83 |
| Root Canal - Molar | $1,171 | N/A | $1,171 |
| X-Ray - Complete Intraoral Series | $137 | N/A | $137 |
| X-Ray - Four Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
