| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $72 | N/A | $72 |
| Dental Exam - Comprehensive | $77 | N/A | $77 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $156 | N/A | $156 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $142 | N/A | $142 |
| Dental Filling - White (Resin): One Surface, Posterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Flouride - Topical Varnish Application | $36 | N/A | $36 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | N/A | $74 |
| Root Canal - Bicuspid Tooth | $820 | N/A | $820 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $42 | N/A | $42 |
| Tooth Extraction - Elevation and/or Forceps Removal | $157 | N/A | $157 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $125 | N/A | $125 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
