| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | N/A | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $332 | N/A | $332 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $272 | N/A | $272 |
| Dental Filling - White (Resin): One Surface, Anterior | $185 | N/A | $185 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $332 | N/A | $332 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $272 | N/A | $272 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $159 | N/A | $159 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | N/A | $288 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Bicuspid Tooth | $1,021 | N/A | $1,021 |
| Root Canal - Molar | $2,039 | N/A | $2,039 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $156 | N/A | $156 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | N/A | $138 |
