| Dental Cleaning - Adult | $118 | N/A | $118 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $111 | N/A | $111 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $238 | N/A | $238 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $410 | N/A | $410 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $323 | N/A | $323 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | N/A | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | N/A | $238 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | N/A | $410 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | N/A | $290 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | N/A | $323 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $180 | N/A | $180 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $319 | N/A | $319 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $99 | N/A | $99 |
| Root Canal - Anterior Tooth | $1,468 | N/A | $1,468 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | N/A | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $170 | N/A | $170 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | N/A | $143 |
