| Dental Cleaning - Adult | $125 | N/A | $125 |
| Dental Cleaning - Child | $101 | N/A | $101 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $408 | N/A | $408 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | N/A | $408 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $181 | N/A | $181 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $169 | N/A | $169 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | N/A | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | N/A | $106 |
| Root Canal - Anterior Tooth | $1,077 | N/A | $1,077 |
| Root Canal - Bicuspid Tooth | $1,235 | N/A | $1,235 |
| Root Canal - Molar | $1,482 | N/A | $1,482 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $340 | N/A | $340 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $174 | N/A | $174 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
