| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $110 | N/A | $110 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $310 | N/A | $310 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | N/A | $310 |
| Flouride - Topical Varnish Application | $63 | N/A | $63 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | N/A | $326 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Molar | $1,575 | N/A | $1,575 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | N/A | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | N/A | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $252 | N/A | $252 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | N/A | $163 |
