| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $224 | N/A | $224 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | N/A | $377 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | N/A | $378 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | N/A | $247 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | N/A | $294 |
| Flouride - Topical Varnish Application | $60 | N/A | $60 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Oral Hygiene Instructions | $40 | N/A | $40 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | N/A | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Root Canal - Bicuspid Tooth | $1,345 | N/A | $1,345 |
| Root Canal - Molar | $1,528 | N/A | $1,528 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | N/A | $169 |
