| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | N/A | $298 |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | N/A | $228 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | N/A | $377 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | N/A | $261 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | N/A | $298 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $166 | N/A | $166 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | N/A | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Root Canal - Bicuspid Tooth | $1,613 | N/A | $1,613 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $222 | N/A | $222 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $170 | N/A | $170 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | N/A | $140 |
