| Dental Cleaning - Adult | $122 | N/A | $122 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $98 | N/A | $98 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | N/A | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $403 | N/A | $403 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $306 | N/A | $306 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $403 | N/A | $403 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | N/A | $306 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | N/A | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Root Canal - Bicuspid Tooth | $1,130 | N/A | $1,130 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | N/A | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $169 | N/A | $169 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
