| Dental Cleaning - Adult | $113 | N/A | $113 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | N/A | $352 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | N/A | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Fluoride - Topical Application | $49 | N/A | $49 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $305 | N/A | $305 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Root Canal - Bicuspid Tooth | $1,071 | N/A | $1,071 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | N/A | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
