| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $106 | N/A | $106 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $386 | N/A | $386 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $193 | N/A | $193 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| 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 | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $182 | N/A | $182 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | N/A | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Root Canal - Anterior Tooth | $956 | N/A | $956 |
| Root Canal - Bicuspid Tooth | $1,024 | N/A | $1,024 |
| Root Canal - Molar | $1,275 | N/A | $1,275 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | N/A | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $192 | N/A | $192 |
| X-Ray - Complete Intraoral Series | $214 | N/A | $214 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | N/A | $143 |
