| Dental Cleaning - Adult | $123 | N/A | $123 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $380 | N/A | $380 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | N/A | $308 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $380 | N/A | $380 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | N/A | $308 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $171 | N/A | $171 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | N/A | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Root Canal - Anterior Tooth | $1,071 | N/A | $1,071 |
| Root Canal - Bicuspid Tooth | $1,213 | N/A | $1,213 |
| Root Canal - Molar | $1,311 | N/A | $1,311 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $179 | N/A | $179 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
