| Dental Cleaning - Adult | $111 | N/A | $111 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | N/A | $177 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | N/A | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | N/A | $245 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | N/A | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | N/A | $177 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | N/A | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | N/A | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $245 | N/A | $245 |
| Flouride - Topical Varnish Application | $39 | N/A | $39 |
| Maintenance Therapy - Periodontal | $212 | N/A | $212 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $105 | N/A | $105 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | N/A | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | N/A | $86 |
| Root Canal - Anterior Tooth | $821 | N/A | $821 |
| Root Canal - Bicuspid Tooth | $1,247 | N/A | $1,247 |
| Root Canal - Molar | $1,176 | N/A | $1,176 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | N/A | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $132 | N/A | $132 |
