| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | N/A | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | N/A | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $343 | N/A | $343 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | N/A | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | N/A | $279 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $164 | N/A | $164 |
| Oral Hygiene Instructions | $66 | N/A | $66 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | N/A | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | N/A | $306 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Anterior Tooth | $1,323 | N/A | $1,323 |
| Root Canal - Molar | $1,785 | N/A | $1,785 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | N/A | $225 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $209 | N/A | $209 |
| X-Ray - Four Images, Bitewings | $80 | N/A | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $56 | N/A | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | N/A | $135 |
