| Dental Cleaning - Adult | $121 | N/A | $121 |
| Dental Cleaning - Child | $102 | N/A | $102 |
| Dental Exam - Comprehensive | $147 | N/A | $147 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | N/A | $209 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | N/A | $298 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | N/A | $298 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $152 | N/A | $152 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $72 | N/A | $72 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $369 | N/A | $369 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $127 | N/A | $127 |
| Root Canal - Anterior Tooth | $880 | N/A | $880 |
| Root Canal - Bicuspid Tooth | $1,024 | N/A | $1,024 |
| Root Canal - Molar | $1,208 | N/A | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | N/A | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $288 | N/A | $288 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $225 | N/A | $225 |
| X-Ray - Four Images, Bitewings | $93 | N/A | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | N/A | $149 |
