| Dental Cleaning - Adult | $148 | N/A | $148 |
| Dental Cleaning - Child | $131 | N/A | $131 |
| Dental Exam - Comprehensive | $119 | N/A | $119 |
| Dental Exam - Periodic, Established Patient | $82 | N/A | $82 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $227 | N/A | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $227 | N/A | $227 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $447 | N/A | $447 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $329 | N/A | $329 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $329 | N/A | $329 |
| Fluoride - Topical Application | $68 | N/A | $68 |
| Maintenance Therapy - Periodontal | $227 | N/A | $227 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $54 | N/A | $54 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $447 | N/A | $447 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Root Canal - Bicuspid Tooth | $1,476 | N/A | $1,476 |
| Root Canal - Molar | $1,849 | N/A | $1,849 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | N/A | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | N/A | $43 |
| X-Ray - Complete Intraoral Series | $317 | N/A | $317 |
| X-Ray - Four Images, Bitewings | $107 | N/A | $107 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Whole Mouth from Outside Mouth | $210 | N/A | $210 |
