| Dental Cleaning - Adult | $170 | N/A | $170 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $130 | N/A | $130 |
| Dental Exam - Periodic, Established Patient | $82 | N/A | $82 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | N/A | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $246 | N/A | $246 |
| Dental Filling - White (Resin): One Surface, Posterior | $267 | N/A | $267 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $431 | N/A | $431 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $343 | N/A | $343 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $376 | N/A | $376 |
| Flouride - Topical Varnish Application | $74 | N/A | $74 |
| Fluoride - Topical Application | $74 | N/A | $74 |
| Maintenance Therapy - Periodontal | $233 | N/A | $233 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $435 | N/A | $435 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | N/A | $130 |
| Root Canal - Anterior Tooth | $1,268 | N/A | $1,268 |
| Root Canal - Bicuspid Tooth | $1,869 | N/A | $1,869 |
| Root Canal - Molar | $1,806 | N/A | $1,806 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $88 | N/A | $88 |
| Tooth Extraction - Elevation and/or Forceps Removal | $267 | N/A | $267 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $257 | N/A | $257 |
| X-Ray - Four Images, Bitewings | $109 | N/A | $109 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | N/A | $48 |
| X-Ray - Two Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Whole Mouth from Outside Mouth | $193 | N/A | $193 |
