| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $101 | N/A | $101 |
| Dental Exam - Periodic, Established Patient | $40 | N/A | $40 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $202 | N/A | $202 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $399 | N/A | $399 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $181 | N/A | $181 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | N/A | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $146 | N/A | $146 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | N/A | $297 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | N/A | $137 |
| Root Canal - Anterior Tooth | $853 | N/A | $853 |
| Root Canal - Bicuspid Tooth | $1,029 | N/A | $1,029 |
| Root Canal - Molar | $1,163 | N/A | $1,163 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $103 | N/A | $103 |
| Tooth Extraction - Elevation and/or Forceps Removal | $332 | N/A | $332 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
