| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | N/A | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $317 | N/A | $317 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $183 | N/A | $183 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | N/A | $348 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | N/A | $279 |
| Flouride - Topical Varnish Application | $38 | N/A | $38 |
| Fluoride - Topical Application | $44 | N/A | $44 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| 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 | $98 | N/A | $98 |
| Root Canal - Anterior Tooth | $996 | N/A | $996 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $250 | N/A | $250 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $181 | N/A | $181 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | N/A | $169 |
