| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Periodic, Established Patient | $45 | N/A | $45 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Oral Hygiene Instructions | $42 | N/A | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $250 | N/A | $250 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Root Canal - Molar | $1,194 | N/A | $1,194 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $151 | N/A | $151 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | N/A | $28 |
| X-Ray - Two Images, Bitewings | $46 | N/A | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $136 | N/A | $136 |
