| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $107 | N/A | $107 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $160 | N/A | $160 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | N/A | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $341 | N/A | $341 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | N/A | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Bicuspid Tooth | $998 | N/A | $998 |
| Root Canal - Molar | $1,785 | N/A | $1,785 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
