| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $222 | N/A | $222 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | N/A | $247 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | N/A | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $788 | N/A | $788 |
| Root Canal - Bicuspid Tooth | $940 | N/A | $940 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | N/A | $47 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $142 | N/A | $142 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
