| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Comprehensive | $99 | N/A | $99 |
| Dental Exam - Periodic, Established Patient | $46 | N/A | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | N/A | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | N/A | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $317 | N/A | $317 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $280 | N/A | $280 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $151 | N/A | $151 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $377 | N/A | $377 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | N/A | $101 |
| Root Canal - Bicuspid Tooth | $1,300 | N/A | $1,300 |
| Root Canal - Molar | $1,758 | N/A | $1,758 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | N/A | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $208 | N/A | $208 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | N/A | $147 |
