| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $97 | N/A | $97 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $380 | N/A | $380 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | N/A | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $253 | N/A | $253 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | N/A | $293 |
| Flouride - Topical Varnish Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $313 | N/A | $313 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Root Canal - Anterior Tooth | $2,048 | N/A | $2,048 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $177 | N/A | $177 |
| X-Ray - Four Images, Bitewings | $83 | N/A | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $151 | N/A | $151 |
