| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $372 | N/A | $372 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | N/A | $372 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | N/A | $289 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $171 | N/A | $171 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $305 | N/A | $305 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $1,232 | N/A | $1,232 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $160 | N/A | $160 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $134 | N/A | $134 |
