| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | N/A | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | N/A | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | N/A | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | N/A | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | N/A | $88 |
| Root Canal - Anterior Tooth | $852 | N/A | $852 |
| Root Canal - Molar | $1,210 | N/A | $1,210 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | N/A | $158 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $145 | N/A | $145 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | N/A | $145 |
