| Dental Cleaning - Adult | $134 | N/A | $134 |
| Dental Cleaning - Child | $99 | N/A | $99 |
| Dental Exam - Comprehensive | $130 | N/A | $130 |
| Dental Exam - Periodic, Established Patient | $70 | N/A | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $281 | N/A | $281 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | N/A | $415 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $357 | N/A | $357 |
| Dental Filling - White (Resin): One Surface, Anterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): One Surface, Posterior | $281 | N/A | $281 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $357 | N/A | $357 |
| Flouride - Topical Varnish Application | $60 | N/A | $60 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Oral Hygiene Instructions | $74 | N/A | $74 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $372 | N/A | $372 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | N/A | $111 |
| Root Canal - Bicuspid Tooth | $1,276 | N/A | $1,276 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | N/A | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | N/A | $165 |
