| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $232 | N/A | $232 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $155 | N/A | $155 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Anterior Tooth | $1,339 | N/A | $1,339 |
| Root Canal - Molar | $1,334 | N/A | $1,334 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | N/A | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
