| Dental Cleaning - Adult | $123 | N/A | $123 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $123 | N/A | $123 |
| Dental Exam - Periodic, Established Patient | $70 | N/A | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $243 | N/A | $243 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | N/A | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $301 | N/A | $301 |
| Dental Filling - White (Resin): One Surface, Anterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): One Surface, Posterior | $243 | N/A | $243 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $375 | N/A | $375 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $280 | N/A | $280 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $301 | N/A | $301 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Oral Hygiene Instructions | $39 | N/A | $39 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $343 | N/A | $343 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Bicuspid Tooth | $1,099 | N/A | $1,099 |
| Root Canal - Molar | $1,351 | N/A | $1,351 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| 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 | $91 | N/A | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | N/A | $43 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
