| Dental Cleaning - Adult | $133 | N/A | $133 |
| Dental Cleaning - Child | $104 | N/A | $104 |
| Dental Exam - Comprehensive | $109 | N/A | $109 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $232 | N/A | $232 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $254 | N/A | $254 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $221 | N/A | $221 |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | N/A | $201 |
| Dental Filling - White (Resin): One Surface, Posterior | $232 | N/A | $232 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | N/A | $389 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | N/A | $302 |
| Flouride - Topical Varnish Application | $47 | N/A | $47 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $180 | N/A | $180 |
| Oral Hygiene Instructions | $46 | N/A | $46 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | N/A | $93 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $328 | N/A | $328 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Anterior Tooth | $1,215 | N/A | $1,215 |
| Root Canal - Bicuspid Tooth | $1,511 | N/A | $1,511 |
| Root Canal - Molar | $1,741 | N/A | $1,741 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | N/A | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | N/A | $216 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $177 | N/A | $177 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $155 | N/A | $155 |
