| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | N/A | $225 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | N/A | $313 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $190 | N/A | $190 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | N/A | $255 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $190 | N/A | $190 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $431 | N/A | $431 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Bicuspid Tooth | $1,896 | N/A | $1,896 |
| Root Canal - Molar | $1,572 | N/A | $1,572 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | N/A | $202 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $217 | N/A | $217 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | N/A | $161 |
