| 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 | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| 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 | $204 | N/A | $204 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $150 | N/A | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $868 | N/A | $868 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $203 | N/A | $203 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
