| Dental Cleaning - Adult | $95 | N/A | $95 |
| Dental Cleaning - Child | $68 | N/A | $68 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | N/A | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $437 | N/A | $437 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $185 | N/A | $185 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $204 | N/A | $204 |
| Flouride - Topical Varnish Application | $84 | N/A | $84 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Maintenance Therapy - Periodontal | $231 | N/A | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Root Canal - Bicuspid Tooth | $1,034 | N/A | $1,034 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $50 | N/A | $50 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | N/A | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $130 | N/A | $130 |
| X-Ray - Four Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
