| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | N/A | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $379 | N/A | $379 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $379 | N/A | $379 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $249 | N/A | $249 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $292 | N/A | $292 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $163 | N/A | $163 |
| Oral Hygiene Instructions | $47 | N/A | $47 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | N/A | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Root Canal - Anterior Tooth | $1,066 | N/A | $1,066 |
| Root Canal - Bicuspid Tooth | $1,315 | N/A | $1,315 |
| Root Canal - Molar | $3,005 | N/A | $3,005 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | N/A | $225 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | N/A | $143 |
