| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $92 | N/A | $92 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $399 | N/A | $399 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | N/A | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $399 | N/A | $399 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | N/A | $266 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $322 | N/A | $322 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | N/A | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Root Canal - Anterior Tooth | $1,200 | N/A | $1,200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $186 | N/A | $186 |
| X-Ray - Four Images, Bitewings | $90 | N/A | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | N/A | $45 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
