| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $116 | N/A | $116 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | N/A | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $291 | N/A | $291 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $336 | N/A | $336 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $285 | N/A | $285 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $452 | N/A | $452 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | N/A | $205 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | N/A | $79 |
| Root Canal - Anterior Tooth | $893 | N/A | $893 |
| Root Canal - Bicuspid Tooth | $1,103 | N/A | $1,103 |
| Root Canal - Molar | $1,365 | N/A | $1,365 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $170 | N/A | $170 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Whole Mouth from Outside Mouth | $189 | N/A | $189 |
