| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | N/A | $201 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | N/A | $344 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | N/A | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $69 | N/A | $69 |
| Maintenance Therapy - Periodontal | $154 | N/A | $154 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $281 | N/A | $281 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Bicuspid Tooth | $1,113 | N/A | $1,113 |
| Root Canal - Molar | $1,365 | N/A | $1,365 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $152 | N/A | $152 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $50 | N/A | $50 |
