| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $68 | N/A | $68 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $145 | N/A | $145 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | N/A | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $289 | N/A | $289 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | N/A | $236 |
| Fluoride - Topical Application | $32 | N/A | $32 |
| Maintenance Therapy - Periodontal | $131 | N/A | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | N/A | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | N/A | $79 |
| Root Canal - Bicuspid Tooth | $945 | N/A | $945 |
| Root Canal - Molar | $1,208 | N/A | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | N/A | $47 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $16 | N/A | $16 |
| X-Ray - Complete Intraoral Series | $142 | N/A | $142 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
