| Dental Cleaning - Adult | $128 | N/A | $128 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | N/A | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | N/A | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $300 | N/A | $300 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | N/A | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | N/A | $358 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | N/A | $320 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Anterior Tooth | $1,103 | N/A | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $441 | N/A | $441 |
| X-Ray - Complete Intraoral Series | $180 | N/A | $180 |
| X-Ray - Four Images, Bitewings | $100 | N/A | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
| X-Ray - Two Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | N/A | $182 |
