| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $143 | N/A | $143 |
| Dental Exam - Comprehensive | $106 | N/A | $106 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | N/A | $225 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | N/A | $277 |
| Dental Filling - White (Resin): One Surface, Posterior | $217 | N/A | $217 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | N/A | $315 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $244 | N/A | $244 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | N/A | $277 |
| Fluoride - Topical Application | $62 | N/A | $62 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | N/A | $306 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Bicuspid Tooth | $1,495 | N/A | $1,495 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | N/A | $82 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | N/A | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
