| Dental Cleaning - Adult | $137 | N/A | $137 |
| Dental Cleaning - Child | $137 | N/A | $137 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | N/A | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | N/A | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | N/A | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | N/A | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | N/A | $257 |
| Fluoride - Topical Application | $84 | N/A | $84 |
| Maintenance Therapy - Periodontal | $194 | N/A | $194 |
| Oral Hygiene Instructions | $53 | N/A | $53 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $79 | N/A | $79 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | N/A | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Anterior Tooth | $735 | N/A | $735 |
| Root Canal - Bicuspid Tooth | $893 | N/A | $893 |
| Root Canal - Molar | $1,050 | N/A | $1,050 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | N/A | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | N/A | $168 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | N/A | $42 |
| X-Ray - Complete Intraoral Series | $273 | N/A | $273 |
| X-Ray - Four Images, Bitewings | $105 | N/A | $105 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Whole Mouth from Outside Mouth | $210 | N/A | $210 |
