| Dental Cleaning - Adult | $102 | N/A | $102 |
| Dental Cleaning - Child | $82 | N/A | $82 |
| Dental Exam - Comprehensive | $88 | N/A | $88 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | N/A | $142 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | N/A | $176 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | N/A | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | N/A | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | N/A | $257 |
| Flouride - Topical Varnish Application | $40 | N/A | $40 |
| Maintenance Therapy - Periodontal | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | N/A | $272 |
| Root Canal - Anterior Tooth | $877 | N/A | $877 |
| Root Canal - Bicuspid Tooth | $951 | N/A | $951 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $111 | N/A | $111 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | N/A | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $143 | N/A | $143 |
| X-Ray - Four Images, Bitewings | $69 | N/A | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | N/A | $33 |
| X-Ray - Two Images, Bitewings | $49 | N/A | $49 |
