| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | N/A | $225 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | N/A | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | N/A | $351 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $313 | N/A | $313 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Bicuspid Tooth | $1,019 | N/A | $1,019 |
| Root Canal - Molar | $2,520 | N/A | $2,520 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | N/A | $63 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
