| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $176 | N/A | $176 |
| Dental Exam - Comprehensive | $114 | N/A | $114 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $285 | N/A | $285 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | N/A | $291 |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | N/A | $213 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | N/A | $299 |
| Flouride - Topical Varnish Application | $95 | N/A | $95 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Root Canal - Bicuspid Tooth | $1,103 | N/A | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $126 | N/A | $126 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | N/A | $240 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $228 | N/A | $228 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | N/A | $145 |
