| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | N/A | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | N/A | $265 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $154 | N/A | $154 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $578 | N/A | $578 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Anterior Tooth | $866 | N/A | $866 |
| Root Canal - Bicuspid Tooth | $998 | N/A | $998 |
| Root Canal - Molar | $1,208 | N/A | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | N/A | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $230 | N/A | $230 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | N/A | $156 |
