| Dental Cleaning - Adult | $112 | N/A | $112 |
| Dental Cleaning - Child | $90 | N/A | $90 |
| Dental Exam - Comprehensive | $104 | N/A | $104 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $372 | N/A | $372 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | N/A | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $206 | N/A | $206 |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | N/A | $216 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | N/A | $372 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | N/A | $255 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | N/A | $286 |
| Flouride - Topical Varnish Application | $45 | N/A | $45 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $161 | N/A | $161 |
| Oral Hygiene Instructions | $46 | N/A | $46 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $130 | N/A | $130 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | N/A | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | N/A | $93 |
| Root Canal - Anterior Tooth | $921 | N/A | $921 |
| Root Canal - Bicuspid Tooth | $1,037 | N/A | $1,037 |
| Root Canal - Molar | $1,934 | N/A | $1,934 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | N/A | $62 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | N/A | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $182 | N/A | $182 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
| X-Ray - Two Images, Bitewings | $60 | N/A | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | N/A | $138 |
