| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $124 | N/A | $124 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $264 | N/A | $264 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $424 | N/A | $424 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $328 | N/A | $328 |
| Dental Filling - White (Resin): One Surface, Anterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): One Surface, Posterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $412 | N/A | $412 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $288 | N/A | $288 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $328 | N/A | $328 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $201 | N/A | $201 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $358 | N/A | $358 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | N/A | $109 |
| Root Canal - Bicuspid Tooth | $1,218 | N/A | $1,218 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | N/A | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $250 | N/A | $250 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $181 | N/A | $181 |
| X-Ray - Four Images, Bitewings | $87 | N/A | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | N/A | $165 |
