| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $68 | N/A | $68 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $192 | N/A | $192 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $308 | N/A | $308 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | N/A | $252 |
| Fluoride - Topical Application | $39 | N/A | $39 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $321 | N/A | $321 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Root Canal - Molar | $1,050 | N/A | $1,050 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $149 | N/A | $149 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $40 | N/A | $40 |
