| Dental Cleaning - Adult | $117 | N/A | $117 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $214 | N/A | $214 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | N/A | $374 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | N/A | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $214 | N/A | $214 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | N/A | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $230 | N/A | $230 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | N/A | $289 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $174 | N/A | $174 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | N/A | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Molar | $1,703 | N/A | $1,703 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $289 | N/A | $289 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $233 | N/A | $233 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | N/A | $145 |
