| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Fluoride - Topical Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $151 | N/A | $151 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $294 | N/A | $294 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | N/A | $108 |
| Root Canal - Bicuspid Tooth | $987 | N/A | $987 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $185 | N/A | $185 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $242 | N/A | $242 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
