| Dental Cleaning - Adult | $96 | N/A | $96 |
| Dental Cleaning - Child | $72 | N/A | $72 |
| Dental Exam - Comprehensive | $102 | N/A | $102 |
| Dental Exam - Periodic, Established Patient | $43 | N/A | $43 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | N/A | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | N/A | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | N/A | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Flouride - Topical Varnish Application | $38 | N/A | $38 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $138 | N/A | $138 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $91 | N/A | $91 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $285 | N/A | $285 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $735 | N/A | $735 |
| Root Canal - Bicuspid Tooth | $1,024 | N/A | $1,024 |
| Root Canal - Molar | $1,231 | N/A | $1,231 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $50 | N/A | $50 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | N/A | $155 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | N/A | $24 |
| X-Ray - Complete Intraoral Series | $153 | N/A | $153 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $44 | N/A | $44 |
