| Dental Cleaning - Adult | $102 | N/A | $102 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $327 | N/A | $327 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $327 | N/A | $327 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $206 | N/A | $206 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $135 | N/A | $135 |
| 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 | $88 | N/A | $88 |
| Root Canal - Anterior Tooth | $945 | N/A | $945 |
| Root Canal - Bicuspid Tooth | $828 | N/A | $828 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | N/A | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $132 | N/A | $132 |
