| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $103 | N/A | $103 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $212 | N/A | $212 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | N/A | $365 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $293 | N/A | $293 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $234 | N/A | $234 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | N/A | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | N/A | $305 |
| Flouride - Topical Varnish Application | $55 | N/A | $55 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Oral Hygiene Instructions | $60 | N/A | $60 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $632 | N/A | $632 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Anterior Tooth | $2,203 | N/A | $2,203 |
| Root Canal - Bicuspid Tooth | $1,213 | N/A | $1,213 |
| Root Canal - Molar | $1,323 | N/A | $1,323 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $244 | N/A | $244 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $180 | N/A | $180 |
| X-Ray - Four Images, Bitewings | $79 | N/A | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | N/A | $142 |
