| Dental Cleaning - Adult | $108 | N/A | $108 |
| Dental Cleaning - Child | $86 | N/A | $86 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | N/A | $195 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | N/A | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | N/A | $270 |
| Dental Filling - White (Resin): One Surface, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | N/A | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | N/A | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | N/A | $212 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | N/A | $270 |
| Flouride - Topical Varnish Application | $54 | N/A | $54 |
| Fluoride - Topical Application | $54 | N/A | $54 |
| Maintenance Therapy - Periodontal | $149 | N/A | $149 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | N/A | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $274 | N/A | $274 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | N/A | $90 |
| Root Canal - Anterior Tooth | $1,077 | N/A | $1,077 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | N/A | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $151 | N/A | $151 |
| X-Ray - Four Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $150 | N/A | $150 |
