| Dental Cleaning - Adult | $96 | N/A | $96 |
| Dental Cleaning - Child | $77 | N/A | $77 |
| Dental Exam - Comprehensive | $83 | N/A | $83 |
| Dental Exam - Periodic, Established Patient | $41 | N/A | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $169 | N/A | $169 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $285 | N/A | $285 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | N/A | $230 |
| Dental Filling - White (Resin): One Surface, Anterior | $151 | N/A | $151 |
| Dental Filling - White (Resin): One Surface, Posterior | $169 | N/A | $169 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $285 | N/A | $285 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $185 | N/A | $185 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $230 | N/A | $230 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $253 | N/A | $253 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | N/A | $82 |
| Root Canal - Anterior Tooth | $792 | N/A | $792 |
| Root Canal - Molar | $1,114 | N/A | $1,114 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | N/A | $49 |
| Tooth Extraction - Elevation and/or Forceps Removal | $174 | N/A | $174 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | N/A | $25 |
| X-Ray - Complete Intraoral Series | $133 | N/A | $133 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $48 | N/A | $48 |
| X-Ray - Whole Mouth from Outside Mouth | $130 | N/A | $130 |
