| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $217 | N/A | $217 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | N/A | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $269 | N/A | $269 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $274 | N/A | $274 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $124 | N/A | $124 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | N/A | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | N/A | $109 |
| Root Canal - Anterior Tooth | $1,245 | N/A | $1,245 |
| Root Canal - Bicuspid Tooth | $1,326 | N/A | $1,326 |
| Root Canal - Molar | $1,626 | N/A | $1,626 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $275 | N/A | $275 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $170 | N/A | $170 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $155 | N/A | $155 |
