| Dental Cleaning - Adult | $132 | N/A | $132 |
| Dental Cleaning - Child | $103 | N/A | $103 |
| Dental Exam - Comprehensive | $144 | N/A | $144 |
| Dental Exam - Periodic, Established Patient | $60 | N/A | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $433 | N/A | $433 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $355 | N/A | $355 |
| Dental Filling - White (Resin): One Surface, Anterior | $258 | N/A | $258 |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | N/A | $278 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | N/A | $433 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $317 | N/A | $317 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $355 | N/A | $355 |
| Flouride - Topical Varnish Application | $56 | N/A | $56 |
| Fluoride - Topical Application | $56 | N/A | $56 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $169 | N/A | $169 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | N/A | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $122 | N/A | $122 |
| Root Canal - Anterior Tooth | $1,181 | N/A | $1,181 |
| Root Canal - Bicuspid Tooth | $1,148 | N/A | $1,148 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | N/A | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $256 | N/A | $256 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | N/A | $36 |
| X-Ray - Complete Intraoral Series | $286 | N/A | $286 |
| X-Ray - Four Images, Bitewings | $102 | N/A | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | N/A | $46 |
| X-Ray - Two Images, Bitewings | $72 | N/A | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | N/A | $184 |
