| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $80 | N/A | $80 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | N/A | $237 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | N/A | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $360 | N/A | $360 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | N/A | $286 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $154 | N/A | $154 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | N/A | $79 |
| Root Canal - Bicuspid Tooth | $924 | N/A | $924 |
| Root Canal - Molar | $2,205 | N/A | $2,205 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | N/A | $284 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
