| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $85 | N/A | $85 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $64 | N/A | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $234 | N/A | $234 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | N/A | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | N/A | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $240 | N/A | $240 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $255 | N/A | $255 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Root Canal - Anterior Tooth | $1,092 | N/A | $1,092 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $204 | N/A | $204 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $161 | N/A | $161 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | N/A | $138 |
