| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $212 | N/A | $212 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | N/A | $318 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | N/A | $277 |
| Dental Filling - White (Resin): One Surface, Anterior | $170 | N/A | $170 |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | N/A | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $326 | N/A | $326 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | N/A | $277 |
| Flouride - Topical Varnish Application | $64 | N/A | $64 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $565 | N/A | $565 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Root Canal - Anterior Tooth | $986 | N/A | $986 |
| Root Canal - Bicuspid Tooth | $1,177 | N/A | $1,177 |
| Root Canal - Molar | $1,491 | N/A | $1,491 |
| Tooth Extraction - Elevation and/or Forceps Removal | $213 | N/A | $213 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $198 | N/A | $198 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Whole Mouth from Outside Mouth | $292 | N/A | $292 |
