| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $89 | N/A | $89 |
| Dental Exam - Periodic, Established Patient | $49 | N/A | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | N/A | $186 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | N/A | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $137 | N/A | $137 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $473 | N/A | $473 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $326 | N/A | $326 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | N/A | $298 |
| Flouride - Topical Varnish Application | $35 | N/A | $35 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $149 | N/A | $149 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | N/A | $272 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Root Canal - Anterior Tooth | $843 | N/A | $843 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | N/A | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $163 | N/A | $163 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $144 | N/A | $144 |
| X-Ray - Four Images, Bitewings | $70 | N/A | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | N/A | $127 |
