| Dental Cleaning - Adult | $120 | N/A | $120 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $113 | N/A | $113 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | N/A | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | N/A | $394 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | N/A | $303 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Oral Hygiene Instructions | $49 | N/A | $49 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $323 | N/A | $323 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Root Canal - Anterior Tooth | $1,976 | N/A | $1,976 |
| Root Canal - Bicuspid Tooth | $1,126 | N/A | $1,126 |
| Root Canal - Molar | $1,398 | N/A | $1,398 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $177 | N/A | $177 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
