| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | N/A | $211 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $363 | N/A | $363 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $186 | N/A | $186 |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | N/A | $211 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $363 | N/A | $363 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $223 | N/A | $223 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | N/A | $294 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | N/A | $303 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Root Canal - Anterior Tooth | $946 | N/A | $946 |
| Root Canal - Bicuspid Tooth | $1,049 | N/A | $1,049 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $211 | N/A | $211 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $151 | N/A | $151 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
