| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $81 | N/A | $81 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $54 | N/A | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | N/A | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $387 | N/A | $387 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $206 | N/A | $206 |
| Dental Filling - White (Resin): One Surface, Anterior | $206 | N/A | $206 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | N/A | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $264 | N/A | $264 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $274 | N/A | $274 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | N/A | $85 |
| Root Canal - Anterior Tooth | $810 | N/A | $810 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | N/A | $22 |
| X-Ray - Complete Intraoral Series | $144 | N/A | $144 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | N/A | $143 |
