| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $160 | N/A | $160 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | N/A | $354 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | N/A | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $155 | N/A | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | N/A | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | N/A | $121 |
| Root Canal - Bicuspid Tooth | $992 | N/A | $992 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | N/A | $182 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $150 | N/A | $150 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $150 | N/A | $150 |
