| Dental Cleaning - Adult | $123 | N/A | $123 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $138 | N/A | $138 |
| Dental Exam - Periodic, Established Patient | $55 | N/A | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | N/A | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | N/A | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $302 | N/A | $302 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | N/A | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | N/A | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | N/A | $302 |
| Flouride - Topical Varnish Application | $53 | N/A | $53 |
| Maintenance Therapy - Periodontal | $162 | N/A | $162 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $46 | N/A | $46 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $291 | N/A | $291 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | N/A | $105 |
| Root Canal - Bicuspid Tooth | $1,082 | N/A | $1,082 |
| Root Canal - Molar | $1,308 | N/A | $1,308 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | N/A | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $203 | N/A | $203 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | N/A | $29 |
| X-Ray - Complete Intraoral Series | $168 | N/A | $168 |
| X-Ray - Four Images, Bitewings | $81 | N/A | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $57 | N/A | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $162 | N/A | $162 |
