| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $131 | N/A | $131 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | N/A | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $332 | N/A | $332 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $247 | N/A | $247 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $305 | N/A | $305 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $267 | N/A | $267 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | N/A | $247 |
| Flouride - Topical Varnish Application | $63 | N/A | $63 |
| Fluoride - Topical Application | $61 | N/A | $61 |
| Maintenance Therapy - Periodontal | $210 | N/A | $210 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $481 | N/A | $481 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | N/A | $121 |
| Root Canal - Anterior Tooth | $1,213 | N/A | $1,213 |
| Root Canal - Bicuspid Tooth | $1,323 | N/A | $1,323 |
| Root Canal - Molar | $1,433 | N/A | $1,433 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | N/A | $265 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $237 | N/A | $237 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
