| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $97 | N/A | $97 |
| Dental Exam - Periodic, Established Patient | $67 | N/A | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | N/A | $225 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | N/A | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $384 | N/A | $384 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | N/A | $369 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $470 | N/A | $470 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | N/A | $284 |
| Flouride - Topical Varnish Application | $88 | N/A | $88 |
| Maintenance Therapy - Periodontal | $233 | N/A | $233 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | N/A | $330 |
| Root Canal - Anterior Tooth | $1,844 | N/A | $1,844 |
| Root Canal - Molar | $2,079 | N/A | $2,079 |
| Tooth Extraction - Elevation and/or Forceps Removal | $244 | N/A | $244 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $183 | N/A | $183 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
