| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $169 | N/A | $169 |
| Dental Filling - White (Resin): One Surface, Posterior | $251 | N/A | $251 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $248 | N/A | $248 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $735 | N/A | $735 |
| Root Canal - Bicuspid Tooth | $1,111 | N/A | $1,111 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | N/A | $155 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
