| Dental Cleaning - Adult | $134 | N/A | $134 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $120 | N/A | $120 |
| Dental Exam - Periodic, Established Patient | $69 | N/A | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | N/A | $249 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | N/A | $394 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $317 | N/A | $317 |
| Dental Filling - White (Resin): One Surface, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): One Surface, Posterior | $256 | N/A | $256 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $401 | N/A | $401 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | N/A | $289 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $317 | N/A | $317 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $56 | N/A | $56 |
| Maintenance Therapy - Periodontal | $195 | N/A | $195 |
| Oral Hygiene Instructions | $72 | N/A | $72 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $362 | N/A | $362 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Anterior Tooth | $1,112 | N/A | $1,112 |
| Root Canal - Bicuspid Tooth | $1,250 | N/A | $1,250 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | N/A | $72 |
| Tooth Extraction - Elevation and/or Forceps Removal | $259 | N/A | $259 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | N/A | $41 |
| X-Ray - Complete Intraoral Series | $179 | N/A | $179 |
| X-Ray - Four Images, Bitewings | $99 | N/A | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $160 | N/A | $160 |
