| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $77 | N/A | $77 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $151 | N/A | $151 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Fluoride - Topical Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $235 | N/A | $235 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $868 | N/A | $868 |
| Root Canal - Bicuspid Tooth | $820 | N/A | $820 |
| Root Canal - Molar | $1,219 | N/A | $1,219 |
| Tooth Extraction - Elevation and/or Forceps Removal | $206 | N/A | $206 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $125 | N/A | $125 |
| X-Ray - Four Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | N/A | $129 |
