| Dental Cleaning - Adult | $149 | N/A | $149 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $293 | N/A | $293 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $387 | N/A | $387 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $237 | N/A | $237 |
| Dental Filling - White (Resin): One Surface, Anterior | $195 | N/A | $195 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $376 | N/A | $376 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $286 | N/A | $286 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | N/A | $312 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $267 | N/A | $267 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $144 | N/A | $144 |
| Root Canal - Molar | $1,491 | N/A | $1,491 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $203 | N/A | $203 |
| X-Ray - Four Images, Bitewings | $98 | N/A | $98 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $83 | N/A | $83 |
