| Dental Cleaning - Adult | $124 | N/A | $124 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| 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 | $288 | N/A | $288 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $448 | N/A | $448 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $371 | N/A | $371 |
| Dental Filling - White (Resin): One Surface, Anterior | $293 | N/A | $293 |
| Dental Filling - White (Resin): One Surface, Posterior | $288 | N/A | $288 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $448 | N/A | $448 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $323 | N/A | $323 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $371 | N/A | $371 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $184 | N/A | $184 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $118 | N/A | $118 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $338 | N/A | $338 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Root Canal - Bicuspid Tooth | $2,310 | N/A | $2,310 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | N/A | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | N/A | $39 |
| X-Ray - Complete Intraoral Series | $179 | N/A | $179 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | N/A | $179 |
