| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $112 | N/A | $112 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | N/A | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $356 | N/A | $356 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $287 | N/A | $287 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | N/A | $223 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $363 | N/A | $363 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $287 | N/A | $287 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | N/A | $318 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | N/A | $104 |
| Root Canal - Bicuspid Tooth | $1,092 | N/A | $1,092 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $169 | N/A | $169 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $172 | N/A | $172 |
