| Dental Cleaning - Adult | $139 | N/A | $139 |
| Dental Cleaning - Child | $83 | N/A | $83 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $204 | N/A | $204 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $307 | N/A | $307 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $320 | N/A | $320 |
| Dental Filling - White (Resin): One Surface, Posterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | N/A | $290 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $320 | N/A | $320 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $71 | N/A | $71 |
| Maintenance Therapy - Periodontal | $198 | N/A | $198 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $369 | N/A | $369 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Anterior Tooth | $1,974 | N/A | $1,974 |
| Root Canal - Bicuspid Tooth | $1,150 | N/A | $1,150 |
| Root Canal - Molar | $1,470 | N/A | $1,470 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | N/A | $82 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $197 | N/A | $197 |
| X-Ray - Four Images, Bitewings | $100 | N/A | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | N/A | $48 |
| X-Ray - Two Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $189 | N/A | $189 |
