| Dental Cleaning - Adult | $95 | N/A | $95 |
| Dental Cleaning - Child | $70 | N/A | $70 |
| Dental Exam - Comprehensive | $77 | N/A | $77 |
| Dental Exam - Periodic, Established Patient | $44 | N/A | $44 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $126 | N/A | $126 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $262 | N/A | $262 |
| Dental Filling - White (Resin): One Surface, Anterior | $140 | N/A | $140 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $254 | N/A | $254 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $462 | N/A | $462 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | N/A | $75 |
| Root Canal - Anterior Tooth | $735 | N/A | $735 |
| Root Canal - Bicuspid Tooth | $840 | N/A | $840 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | N/A | $48 |
| Tooth Extraction - Elevation and/or Forceps Removal | $154 | N/A | $154 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | N/A | $23 |
| X-Ray - Complete Intraoral Series | $126 | N/A | $126 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
| X-Ray - Whole Mouth from Outside Mouth | $116 | N/A | $116 |
