| Dental Cleaning - Adult | $98 | N/A | $98 |
| Dental Cleaning - Child | $78 | N/A | $78 |
| Dental Exam - Comprehensive | $90 | N/A | $90 |
| Dental Exam - Periodic, Established Patient | $47 | N/A | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | N/A | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | N/A | $310 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | N/A | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $185 | N/A | $185 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | N/A | $310 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | N/A | $242 |
| Flouride - Topical Varnish Application | $41 | N/A | $41 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $46 | N/A | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | N/A | $89 |
| Root Canal - Anterior Tooth | $861 | N/A | $861 |
| Root Canal - Bicuspid Tooth | $966 | N/A | $966 |
| Root Canal - Molar | $1,155 | N/A | $1,155 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | N/A | $183 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $138 | N/A | $138 |
| X-Ray - Four Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | N/A | $34 |
| X-Ray - Two Images, Bitewings | $101 | N/A | $101 |
