| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $418 | N/A | $418 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $361 | N/A | $361 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | N/A | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $180 | N/A | $180 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $328 | N/A | $328 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Root Canal - Bicuspid Tooth | $1,179 | N/A | $1,179 |
| Root Canal - Molar | $1,463 | N/A | $1,463 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $254 | N/A | $254 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $177 | N/A | $177 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $120 | N/A | $120 |
