| Dental Cleaning - Adult | $95 | N/A | $95 |
| Dental Cleaning - Child | $66 | N/A | $66 |
| Dental Exam - Comprehensive | $86 | N/A | $86 |
| Dental Exam - Periodic, Established Patient | $41 | N/A | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $147 | N/A | $147 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $260 | N/A | $260 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $131 | N/A | $131 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $260 | N/A | $260 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $186 | N/A | $186 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | N/A | $205 |
| Root Canal - Bicuspid Tooth | $1,103 | N/A | $1,103 |
| Root Canal - Molar | $1,103 | N/A | $1,103 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | N/A | $168 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | N/A | $22 |
| X-Ray - Complete Intraoral Series | $139 | N/A | $139 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | N/A | $29 |
| X-Ray - Two Images, Bitewings | $41 | N/A | $41 |
