| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | N/A | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Maintenance Therapy - Periodontal | $147 | N/A | $147 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | N/A | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Molar | $1,339 | N/A | $1,339 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $242 | N/A | $242 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
