| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $93 | N/A | $93 |
| Dental Exam - Comprehensive | $126 | N/A | $126 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $197 | N/A | $197 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | N/A | $348 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $176 | N/A | $176 |
| Dental Filling - White (Resin): One Surface, Posterior | $197 | N/A | $197 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | N/A | $348 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | N/A | $278 |
| Flouride - Topical Varnish Application | $44 | N/A | $44 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $171 | N/A | $171 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | N/A | $93 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $294 | N/A | $294 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Anterior Tooth | $877 | N/A | $877 |
| Root Canal - Bicuspid Tooth | $1,982 | N/A | $1,982 |
| Root Canal - Molar | $1,229 | N/A | $1,229 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | N/A | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $193 | N/A | $193 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $158 | N/A | $158 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | N/A | $158 |
