| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | N/A | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | N/A | $404 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | N/A | $404 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | N/A | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Anterior Tooth | $1,381 | N/A | $1,381 |
| Root Canal - Bicuspid Tooth | $1,486 | N/A | $1,486 |
| Root Canal - Molar | $1,696 | N/A | $1,696 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $368 | N/A | $368 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
