| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $102 | N/A | $102 |
| Dental Exam - Comprehensive | $109 | N/A | $109 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $412 | N/A | $412 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | N/A | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): One Surface, Posterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $412 | N/A | $412 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | N/A | $288 |
| Fluoride - Topical Application | $70 | N/A | $70 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $349 | N/A | $349 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Root Canal - Anterior Tooth | $1,323 | N/A | $1,323 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $277 | N/A | $277 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $218 | N/A | $218 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
