| Dental Cleaning - Adult | $104 | N/A | $104 |
| Dental Cleaning - Child | $76 | N/A | $76 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $187 | N/A | $187 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $332 | N/A | $332 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $258 | N/A | $258 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $332 | N/A | $332 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $258 | N/A | $258 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $139 | N/A | $139 |
| Oral Hygiene Instructions | $44 | N/A | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | N/A | $254 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $801 | N/A | $801 |
| Root Canal - Bicuspid Tooth | $1,394 | N/A | $1,394 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | N/A | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | N/A | $25 |
| X-Ray - Complete Intraoral Series | $145 | N/A | $145 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
