| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | N/A | $268 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Bicuspid Tooth | $1,050 | N/A | $1,050 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
