| Dental Cleaning - Adult | $142 | N/A | $142 |
| Dental Exam - Comprehensive | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | N/A | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | N/A | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | N/A | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | N/A | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $65 | N/A | $65 |
| Maintenance Therapy - Periodontal | $193 | N/A | $193 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $132 | N/A | $132 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | N/A | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | N/A | $108 |
| Root Canal - Bicuspid Tooth | $1,300 | N/A | $1,300 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $191 | N/A | $191 |
| X-Ray - Four Images, Bitewings | $110 | N/A | $110 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | N/A | $44 |
