| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | N/A | $195 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | N/A | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | N/A | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | N/A | $260 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | N/A | $273 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Root Canal - Bicuspid Tooth | $966 | N/A | $966 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | N/A | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | N/A | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $151 | N/A | $151 |
| X-Ray - Four Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
