| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $333 | N/A | $333 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | N/A | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | N/A | $265 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Fluoride - Topical Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $154 | N/A | $154 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Bicuspid Tooth | $979 | N/A | $979 |
| Root Canal - Molar | $1,219 | N/A | $1,219 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
