| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $87 | N/A | $87 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | N/A | $201 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $169 | N/A | $169 |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $203 | N/A | $203 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $151 | N/A | $151 |
| Oral Hygiene Instructions | $56 | N/A | $56 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | N/A | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | N/A | $85 |
| Root Canal - Anterior Tooth | $742 | N/A | $742 |
| Root Canal - Bicuspid Tooth | $899 | N/A | $899 |
| 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 | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $148 | N/A | $148 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
