| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $102 | N/A | $102 |
| Dental Exam - Comprehensive | $114 | N/A | $114 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $183 | N/A | $183 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | N/A | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $256 | N/A | $256 |
| Dental Filling - White (Resin): One Surface, Anterior | $224 | N/A | $224 |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | N/A | $244 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | N/A | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $61 | N/A | $61 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $164 | N/A | $164 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $358 | N/A | $358 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | N/A | $111 |
| Root Canal - Bicuspid Tooth | $1,455 | N/A | $1,455 |
| Root Canal - Molar | $1,999 | N/A | $1,999 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | N/A | $83 |
| Tooth Extraction - Elevation and/or Forceps Removal | $270 | N/A | $270 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | N/A | $42 |
| X-Ray - Complete Intraoral Series | $190 | N/A | $190 |
| X-Ray - Four Images, Bitewings | $97 | N/A | $97 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | N/A | $170 |
