| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | N/A | $239 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $277 | N/A | $277 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | N/A | $223 |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | N/A | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | N/A | $302 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | N/A | $336 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Root Canal - Bicuspid Tooth | $1,217 | N/A | $1,217 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | N/A | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $172 | N/A | $172 |
| X-Ray - Four Images, Bitewings | $87 | N/A | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
