| Dental Cleaning - Adult | $107 | N/A | $107 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $109 | N/A | $109 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | N/A | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $192 | N/A | $192 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $342 | N/A | $342 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $599 | N/A | $599 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | N/A | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $468 | N/A | $468 |
| Flouride - Topical Varnish Application | $43 | N/A | $43 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $231 | N/A | $231 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $79 | N/A | $79 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $540 | N/A | $540 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | N/A | $100 |
| Root Canal - Anterior Tooth | $885 | N/A | $885 |
| Root Canal - Bicuspid Tooth | $988 | N/A | $988 |
| Root Canal - Molar | $1,726 | N/A | $1,726 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | N/A | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $252 | N/A | $252 |
| 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 | $131 | N/A | $131 |
