| Dental Cleaning - Adult | $216 | N/A | $216 |
| Dental Cleaning - Child | $185 | N/A | $185 |
| Dental Exam - Comprehensive | $181 | N/A | $181 |
| Dental Exam - Periodic, Established Patient | $99 | N/A | $99 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $684 | N/A | $684 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $410 | N/A | $410 |
| Dental Filling - White (Resin): One Surface, Anterior | $291 | N/A | $291 |
| Dental Filling - White (Resin): One Surface, Posterior | $268 | N/A | $268 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $683 | N/A | $683 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $323 | N/A | $323 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Root Canal - Anterior Tooth | $1,796 | N/A | $1,796 |
| Root Canal - Bicuspid Tooth | $1,008 | N/A | $1,008 |
| Root Canal - Molar | $2,415 | N/A | $2,415 |
| Tooth Extraction - Elevation and/or Forceps Removal | $399 | N/A | $399 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $228 | N/A | $228 |
| X-Ray - Four Images, Bitewings | $160 | N/A | $160 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
