| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $50 | N/A | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | N/A | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | N/A | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $180 | N/A | $180 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | N/A | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $214 | N/A | $214 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | N/A | $263 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $153 | N/A | $153 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | N/A | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | N/A | $95 |
| Root Canal - Bicuspid Tooth | $1,029 | N/A | $1,029 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | N/A | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $149 | N/A | $149 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | N/A | $137 |
