| Dental Cleaning - Adult | $129 | N/A | $129 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $129 | N/A | $129 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $229 | N/A | $229 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | N/A | $415 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | N/A | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Flouride - Topical Varnish Application | $63 | N/A | $63 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $355 | N/A | $355 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Molar | $1,785 | N/A | $1,785 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $257 | N/A | $257 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $189 | N/A | $189 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $162 | N/A | $162 |
