| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $107 | N/A | $107 |
| Dental Exam - Comprehensive | $139 | N/A | $139 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $275 | N/A | $275 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $370 | N/A | $370 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - White (Resin): One Surface, Anterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | N/A | $348 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $275 | N/A | $275 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $231 | N/A | $231 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $540 | N/A | $540 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Bicuspid Tooth | $983 | N/A | $983 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | N/A | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $252 | N/A | $252 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $101 | N/A | $101 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
