| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $91 | N/A | $91 |
| Dental Exam - Comprehensive | $105 | N/A | $105 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | N/A | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | N/A | $365 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | N/A | $291 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $371 | N/A | $371 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $224 | N/A | $224 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $291 | N/A | $291 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Fluoride - Topical Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $160 | N/A | $160 |
| Oral Hygiene Instructions | $45 | N/A | $45 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $153 | N/A | $153 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | N/A | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | N/A | $98 |
| Root Canal - Anterior Tooth | $929 | N/A | $929 |
| Root Canal - Bicuspid Tooth | $1,023 | N/A | $1,023 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $229 | N/A | $229 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | N/A | $30 |
| X-Ray - Complete Intraoral Series | $196 | N/A | $196 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | N/A | $153 |
