| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $111 | N/A | $111 |
| Dental Exam - Comprehensive | $97 | N/A | $97 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $361 | N/A | $361 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | N/A | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | N/A | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $292 | N/A | $292 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | N/A | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Root Canal - Anterior Tooth | $870 | N/A | $870 |
| Root Canal - Bicuspid Tooth | $1,049 | N/A | $1,049 |
| Root Canal - Molar | $1,378 | N/A | $1,378 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | N/A | $40 |
| X-Ray - Complete Intraoral Series | $185 | N/A | $185 |
| X-Ray - Four Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
