| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $233 | N/A | $233 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | N/A | $276 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $159 | N/A | $159 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $449 | N/A | $449 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Bicuspid Tooth | $1,028 | N/A | $1,028 |
| Root Canal - Molar | $1,319 | N/A | $1,319 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $192 | N/A | $192 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $153 | N/A | $153 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
