| Dental Cleaning - Adult | $145 | N/A | $145 |
| Dental Cleaning - Child | $118 | N/A | $118 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | N/A | $173 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $173 | N/A | $173 |
| Dental Filling - White (Resin): One Surface, Anterior | $152 | N/A | $152 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | N/A | $215 |
| Fluoride - Topical Application | $71 | N/A | $71 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $242 | N/A | $242 |
| Root Canal - Anterior Tooth | $840 | N/A | $840 |
| Root Canal - Bicuspid Tooth | $866 | N/A | $866 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | N/A | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $163 | N/A | $163 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
