| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $110 | N/A | $110 |
| Dental Exam - Periodic, Established Patient | $62 | N/A | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | N/A | $239 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $311 | N/A | $311 |
| Dental Filling - White (Resin): One Surface, Anterior | $230 | N/A | $230 |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | N/A | $311 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $179 | N/A | $179 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $148 | N/A | $148 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $337 | N/A | $337 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Anterior Tooth | $1,966 | N/A | $1,966 |
| Root Canal - Bicuspid Tooth | $1,121 | N/A | $1,121 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $58 | N/A | $58 |
