| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | N/A | $166 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Anterior | $166 | N/A | $166 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $193 | N/A | $193 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $208 | N/A | $208 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $200 | N/A | $200 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $66 | N/A | $66 |
| Root Canal - Anterior Tooth | $1,097 | N/A | $1,097 |
| Root Canal - Bicuspid Tooth | $1,195 | N/A | $1,195 |
| Root Canal - Molar | $1,381 | N/A | $1,381 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | N/A | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $143 | N/A | $143 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | N/A | $184 |
