| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $97 | N/A | $97 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $263 | N/A | $263 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $305 | N/A | $305 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $164 | N/A | $164 |
| Oral Hygiene Instructions | $60 | N/A | $60 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | N/A | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Root Canal - Anterior Tooth | $945 | N/A | $945 |
| Root Canal - Bicuspid Tooth | $2,144 | N/A | $2,144 |
| Root Canal - Molar | $1,288 | N/A | $1,288 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
