| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $72 | N/A | $72 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | N/A | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | N/A | $282 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | N/A | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $142 | N/A | $142 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | N/A | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | N/A | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | N/A | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | N/A | $217 |
| Flouride - Topical Varnish Application | $37 | N/A | $37 |
| Maintenance Therapy - Periodontal | $128 | N/A | $128 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $98 | N/A | $98 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | N/A | $75 |
| Root Canal - Anterior Tooth | $1,559 | N/A | $1,559 |
| Root Canal - Bicuspid Tooth | $824 | N/A | $824 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | N/A | $49 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | N/A | $155 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | N/A | $28 |
| X-Ray - Complete Intraoral Series | $125 | N/A | $125 |
| X-Ray - Four Images, Bitewings | $61 | N/A | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $43 | N/A | $43 |
| X-Ray - Whole Mouth from Outside Mouth | $110 | N/A | $110 |
