| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $78 | N/A | $78 |
| Dental Exam - Comprehensive | $121 | N/A | $121 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $364 | N/A | $364 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | N/A | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | N/A | $257 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Fluoride - Topical Application | $40 | N/A | $40 |
| Maintenance Therapy - Periodontal | $140 | N/A | $140 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | N/A | $254 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Root Canal - Molar | $1,304 | N/A | $1,304 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | N/A | $284 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $141 | N/A | $141 |
| X-Ray - Four Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
