| Dental Cleaning - Adult | $128 | N/A | $128 |
| Dental Cleaning - Child | $120 | N/A | $120 |
| Dental Exam - Comprehensive | $108 | N/A | $108 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $225 | N/A | $225 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | N/A | $238 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $401 | N/A | $401 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | N/A | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | N/A | $321 |
| Flouride - Topical Varnish Application | $71 | N/A | $71 |
| Fluoride - Topical Application | $60 | N/A | $60 |
| Maintenance Therapy - Periodontal | $200 | N/A | $200 |
| Oral Hygiene Instructions | $51 | N/A | $51 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $334 | N/A | $334 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | N/A | $108 |
| Root Canal - Anterior Tooth | $1,431 | N/A | $1,431 |
| Root Canal - Bicuspid Tooth | $1,273 | N/A | $1,273 |
| Root Canal - Molar | $2,321 | N/A | $2,321 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | N/A | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $357 | N/A | $357 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $14 | N/A | $14 |
| X-Ray - Complete Intraoral Series | $175 | N/A | $175 |
| X-Ray - Four Images, Bitewings | $89 | N/A | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $76 | N/A | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | N/A | $154 |
