| Dental Cleaning - Adult | $129 | N/A | $129 |
| Dental Cleaning - Child | $96 | N/A | $96 |
| Dental Exam - Comprehensive | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | N/A | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | N/A | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | N/A | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $188 | N/A | $188 |
| Oral Hygiene Instructions | $63 | N/A | $63 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $121 | N/A | $121 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $329 | N/A | $329 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Anterior Tooth | $1,004 | N/A | $1,004 |
| Root Canal - Bicuspid Tooth | $1,151 | N/A | $1,151 |
| Root Canal - Molar | $2,783 | N/A | $2,783 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $250 | N/A | $250 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $210 | N/A | $210 |
| X-Ray - Four Images, Bitewings | $96 | N/A | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | N/A | $163 |
