| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | N/A | $211 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $269 | N/A | $269 |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $326 | N/A | $326 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | N/A | $269 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $161 | N/A | $161 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | N/A | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $889 | N/A | $889 |
| Root Canal - Bicuspid Tooth | $1,026 | N/A | $1,026 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | N/A | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
