| Dental Cleaning - Adult | $139 | N/A | $139 |
| Dental Cleaning - Child | $109 | N/A | $109 |
| Dental Exam - Comprehensive | $206 | N/A | $206 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $279 | N/A | $279 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | N/A | $365 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $302 | N/A | $302 |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | N/A | $211 |
| Dental Filling - White (Resin): One Surface, Posterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $461 | N/A | $461 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $268 | N/A | $268 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $359 | N/A | $359 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $161 | N/A | $161 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $354 | N/A | $354 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Molar | $1,554 | N/A | $1,554 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $270 | N/A | $270 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $208 | N/A | $208 |
| X-Ray - Four Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | N/A | $135 |
