| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $80 | N/A | $80 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | N/A | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | N/A | $373 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $336 | N/A | $336 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | N/A | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Root Canal - Anterior Tooth | $961 | N/A | $961 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
