| Dental Cleaning - Adult | $128 | N/A | $128 |
| Dental Cleaning - Child | $107 | N/A | $107 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | N/A | $306 |
| Flouride - Topical Varnish Application | $66 | N/A | $66 |
| Fluoride - Topical Application | $66 | N/A | $66 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Oral Hygiene Instructions | $68 | N/A | $68 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Anterior Tooth | $1,323 | N/A | $1,323 |
| Root Canal - Bicuspid Tooth | $1,541 | N/A | $1,541 |
| Root Canal - Molar | $1,616 | N/A | $1,616 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $95 | N/A | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $171 | N/A | $171 |
