| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $210 | N/A | $210 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $320 | N/A | $320 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | N/A | $307 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $321 | N/A | $321 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | N/A | $104 |
| Root Canal - Bicuspid Tooth | $1,188 | N/A | $1,188 |
| Root Canal - Molar | $1,428 | N/A | $1,428 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $172 | N/A | $172 |
