| Dental Cleaning - Adult | $103 | N/A | $103 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | N/A | $186 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | N/A | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $237 | N/A | $237 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | N/A | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $187 | N/A | $187 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $149 | N/A | $149 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | N/A | $272 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | N/A | $87 |
| Root Canal - Anterior Tooth | $843 | N/A | $843 |
| Root Canal - Bicuspid Tooth | $828 | N/A | $828 |
| Root Canal - Molar | $1,196 | N/A | $1,196 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | N/A | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | N/A | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $144 | N/A | $144 |
| X-Ray - Four Images, Bitewings | $71 | N/A | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | N/A | $131 |
