| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| 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 | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $169 | N/A | $169 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $307 | N/A | $307 |
| 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 | $89 | N/A | $89 |
| Root Canal - Bicuspid Tooth | $988 | N/A | $988 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | N/A | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | N/A | $45 |
| X-Ray - Complete Intraoral Series | $204 | N/A | $204 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
