| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Comprehensive | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $254 | N/A | $254 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $395 | N/A | $395 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | N/A | $395 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $326 | N/A | $326 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $363 | N/A | $363 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Root Canal - Anterior Tooth | $1,045 | N/A | $1,045 |
| Root Canal - Bicuspid Tooth | $1,181 | N/A | $1,181 |
| Root Canal - Molar | $1,445 | N/A | $1,445 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $271 | N/A | $271 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $171 | N/A | $171 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $166 | N/A | $166 |
