| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $235 | N/A | $235 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | N/A | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $301 | N/A | $301 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | N/A | $373 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $301 | N/A | $301 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | N/A | $318 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Anterior Tooth | $971 | N/A | $971 |
| Root Canal - Bicuspid Tooth | $2,300 | N/A | $2,300 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $272 | N/A | $272 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | N/A | $43 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
