| Dental Cleaning - Adult | $117 | N/A | $117 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $107 | N/A | $107 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | N/A | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $335 | N/A | $335 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | N/A | $276 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | N/A | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $335 | N/A | $335 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | N/A | $276 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $177 | N/A | $177 |
| Oral Hygiene Instructions | $38 | N/A | $38 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | N/A | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | N/A | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | N/A | $92 |
| Root Canal - Anterior Tooth | $910 | N/A | $910 |
| Root Canal - Bicuspid Tooth | $1,046 | N/A | $1,046 |
| Root Canal - Molar | $1,336 | N/A | $1,336 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | N/A | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $222 | N/A | $222 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $216 | N/A | $216 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | N/A | $36 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | N/A | $139 |
