| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | N/A | $313 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | N/A | $313 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | N/A | $261 |
| Flouride - Topical Varnish Application | $32 | N/A | $32 |
| Fluoride - Topical Application | $32 | N/A | $32 |
| Maintenance Therapy - Periodontal | $132 | N/A | $132 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | N/A | $82 |
| Root Canal - Anterior Tooth | $877 | N/A | $877 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | N/A | $51 |
| Tooth Extraction - Elevation and/or Forceps Removal | $174 | N/A | $174 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $137 | N/A | $137 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
