| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | N/A | $222 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $280 | N/A | $280 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $222 | N/A | $222 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $249 | N/A | $249 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $280 | N/A | $280 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | N/A | $303 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $1,323 | N/A | $1,323 |
| Root Canal - Bicuspid Tooth | $1,541 | N/A | $1,541 |
| Root Canal - Molar | $1,785 | N/A | $1,785 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | N/A | $80 |
| 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 | $164 | N/A | $164 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| 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 | $137 | N/A | $137 |
