| Dental Cleaning - Adult | $130 | N/A | $130 |
| Dental Cleaning - Child | $110 | N/A | $110 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | N/A | $244 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | N/A | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | N/A | $244 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $376 | N/A | $376 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $174 | N/A | $174 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | N/A | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Root Canal - Anterior Tooth | $1,037 | N/A | $1,037 |
| Root Canal - Bicuspid Tooth | $1,281 | N/A | $1,281 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $227 | N/A | $227 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | N/A | $43 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | N/A | $161 |
