| Dental Cleaning - Adult | $114 | N/A | $114 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $130 | N/A | $130 |
| Dental Exam - Periodic, Established Patient | $65 | N/A | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | N/A | $209 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | N/A | $334 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $267 | N/A | $267 |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | N/A | $192 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | N/A | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | N/A | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $267 | N/A | $267 |
| Fluoride - Topical Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $168 | N/A | $168 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | N/A | $93 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $383 | N/A | $383 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | N/A | $116 |
| Root Canal - Anterior Tooth | $901 | N/A | $901 |
| Root Canal - Bicuspid Tooth | $1,034 | N/A | $1,034 |
| Root Canal - Molar | $1,279 | N/A | $1,279 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | N/A | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | N/A | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | N/A | $35 |
| X-Ray - Complete Intraoral Series | $211 | N/A | $211 |
| X-Ray - Four Images, Bitewings | $77 | N/A | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $54 | N/A | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $134 | N/A | $134 |
