| Dental Cleaning - Adult | $139 | N/A | $139 |
| Dental Cleaning - Child | $113 | N/A | $113 |
| Dental Exam - Comprehensive | $119 | N/A | $119 |
| Dental Exam - Periodic, Established Patient | $74 | N/A | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | N/A | $249 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $370 | N/A | $370 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $311 | N/A | $311 |
| Dental Filling - White (Resin): One Surface, Anterior | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Posterior | $243 | N/A | $243 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | N/A | $311 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $188 | N/A | $188 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $363 | N/A | $363 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | N/A | $114 |
| Root Canal - Anterior Tooth | $1,128 | N/A | $1,128 |
| Root Canal - Bicuspid Tooth | $1,339 | N/A | $1,339 |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | N/A | $242 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $181 | N/A | $181 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | N/A | $43 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $160 | N/A | $160 |
