| Dental Cleaning - Adult | $138 | N/A | $138 |
| Dental Cleaning - Child | $97 | N/A | $97 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $260 | N/A | $260 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $323 | N/A | $323 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $260 | N/A | $260 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | N/A | $358 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Fluoride - Topical Application | $63 | N/A | $63 |
| Maintenance Therapy - Periodontal | $353 | N/A | $353 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | N/A | $310 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $164 | N/A | $164 |
| Root Canal - Anterior Tooth | $1,031 | N/A | $1,031 |
| Root Canal - Bicuspid Tooth | $1,234 | N/A | $1,234 |
| Root Canal - Molar | $1,460 | N/A | $1,460 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $85 | N/A | $85 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $196 | N/A | $196 |
| X-Ray - Four Images, Bitewings | $91 | N/A | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $200 | N/A | $200 |
