| Dental Cleaning - Adult | $134 | N/A | $134 |
| Dental Cleaning - Child | $107 | N/A | $107 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | N/A | $233 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $435 | N/A | $435 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | N/A | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | N/A | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $435 | N/A | $435 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $285 | N/A | $285 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | N/A | $313 |
| Flouride - Topical Varnish Application | $57 | N/A | $57 |
| Fluoride - Topical Application | $57 | N/A | $57 |
| Root Canal - Anterior Tooth | $1,032 | N/A | $1,032 |
| Root Canal - Bicuspid Tooth | $1,168 | N/A | $1,168 |
| Root Canal - Molar | $1,569 | N/A | $1,569 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | N/A | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | N/A | $242 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | N/A | $38 |
| X-Ray - Complete Intraoral Series | $193 | N/A | $193 |
| X-Ray - Four Images, Bitewings | $96 | N/A | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $75 | N/A | $75 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | N/A | $169 |
