| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | N/A | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $281 | N/A | $281 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | N/A | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | N/A | $281 |
| Flouride - Topical Varnish Application | $30 | N/A | $30 |
| Maintenance Therapy - Periodontal | $146 | N/A | $146 |
| Oral Hygiene Instructions | $58 | N/A | $58 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Root Canal - Molar | $1,360 | N/A | $1,360 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | N/A | $62 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $177 | N/A | $177 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
