| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $202 | N/A | $202 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | N/A | $352 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | N/A | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $155 | N/A | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $599 | N/A | $599 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Root Canal - Anterior Tooth | $887 | N/A | $887 |
| Root Canal - Bicuspid Tooth | $1,019 | N/A | $1,019 |
| Root Canal - Molar | $1,257 | N/A | $1,257 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $223 | N/A | $223 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $144 | N/A | $144 |
