| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $126 | N/A | $126 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | N/A | $236 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | N/A | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Anterior Tooth | $735 | N/A | $735 |
| Root Canal - Bicuspid Tooth | $840 | N/A | $840 |
| Root Canal - Molar | $1,155 | N/A | $1,155 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $185 | N/A | $185 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $7 | N/A | $7 |
| X-Ray - Complete Intraoral Series | $146 | N/A | $146 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
