| Dental Cleaning - Adult | $141 | N/A | $141 |
| Dental Cleaning - Child | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $72 | N/A | $72 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $295 | N/A | $295 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | N/A | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $369 | N/A | $369 |
| Dental Filling - White (Resin): One Surface, Posterior | $295 | N/A | $295 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $440 | N/A | $440 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $380 | N/A | $380 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $369 | N/A | $369 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Maintenance Therapy - Periodontal | $188 | N/A | $188 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $122 | N/A | $122 |
| Root Canal - Anterior Tooth | $1,103 | N/A | $1,103 |
| Root Canal - Bicuspid Tooth | $1,744 | N/A | $1,744 |
| Tooth Extraction - Elevation and/or Forceps Removal | $376 | N/A | $376 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | N/A | $50 |
| X-Ray - Complete Intraoral Series | $225 | N/A | $225 |
| X-Ray - Four Images, Bitewings | $114 | N/A | $114 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | N/A | $50 |
| X-Ray - Two Images, Bitewings | $114 | N/A | $114 |
