| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $93 | N/A | $93 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $343 | N/A | $343 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $269 | N/A | $269 |
| Dental Filling - White (Resin): One Surface, Anterior | $175 | N/A | $175 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $343 | N/A | $343 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $224 | N/A | $224 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | N/A | $269 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Fluoride - Topical Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $456 | N/A | $456 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $1,013 | N/A | $1,013 |
| Root Canal - Bicuspid Tooth | $1,155 | N/A | $1,155 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | N/A | $62 |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | N/A | $218 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $165 | N/A | $165 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
