| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $99 | N/A | $99 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | N/A | $213 |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): One Surface, Posterior | $320 | N/A | $320 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | N/A | $234 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $300 | N/A | $300 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Root Canal - Bicuspid Tooth | $1,273 | N/A | $1,273 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Four Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | N/A | $138 |
