| Dental Cleaning - Adult | $147 | N/A | $147 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $161 | N/A | $161 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $247 | N/A | $247 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $411 | N/A | $411 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $327 | N/A | $327 |
| Dental Filling - White (Resin): One Surface, Anterior | $292 | N/A | $292 |
| Dental Filling - White (Resin): One Surface, Posterior | $303 | N/A | $303 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $399 | N/A | $399 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $431 | N/A | $431 |
| Flouride - Topical Varnish Application | $64 | N/A | $64 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Root Canal - Bicuspid Tooth | $1,290 | N/A | $1,290 |
| Root Canal - Molar | $1,596 | N/A | $1,596 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $91 | N/A | $91 |
| Tooth Extraction - Elevation and/or Forceps Removal | $285 | N/A | $285 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | N/A | $47 |
| X-Ray - Complete Intraoral Series | $223 | N/A | $223 |
| X-Ray - Four Images, Bitewings | $112 | N/A | $112 |
| X-Ray - Intraoral, Periapical Radiographic Image | $54 | N/A | $54 |
| X-Ray - Two Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Whole Mouth from Outside Mouth | $223 | N/A | $223 |
