| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | N/A | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $353 | N/A | $353 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $275 | N/A | $275 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | N/A | $218 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | N/A | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | N/A | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | N/A | $276 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $166 | N/A | $166 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $298 | N/A | $298 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Bicuspid Tooth | $1,059 | N/A | $1,059 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | N/A | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $161 | N/A | $161 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
