| Dental Cleaning - Adult | $129 | N/A | $129 |
| Dental Cleaning - Child | $71 | N/A | $71 |
| Dental Exam - Comprehensive | $114 | N/A | $114 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | N/A | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $331 | N/A | $331 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $193 | N/A | $193 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | N/A | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $255 | N/A | $255 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Fluoride - Topical Application | $36 | N/A | $36 |
| Maintenance Therapy - Periodontal | $190 | N/A | $190 |
| Oral Hygiene Instructions | $53 | N/A | $53 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $340 | N/A | $340 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | N/A | $109 |
| Root Canal - Anterior Tooth | $739 | N/A | $739 |
| Root Canal - Bicuspid Tooth | $1,299 | N/A | $1,299 |
| Root Canal - Molar | $1,541 | N/A | $1,541 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | N/A | $51 |
| Tooth Extraction - Elevation and/or Forceps Removal | $224 | N/A | $224 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | N/A | $161 |
