| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $111 | N/A | $111 |
| Dental Exam - Periodic, Established Patient | $63 | N/A | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | N/A | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $249 | N/A | $249 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | N/A | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | N/A | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | N/A | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | N/A | $282 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $139 | N/A | $139 |
| Oral Hygiene Instructions | $55 | N/A | $55 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | N/A | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | N/A | $96 |
| Root Canal - Bicuspid Tooth | $979 | N/A | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | N/A | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $149 | N/A | $149 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
