| Dental Cleaning - Adult | $132 | N/A | $132 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $132 | N/A | $132 |
| Dental Exam - Periodic, Established Patient | $79 | N/A | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | N/A | $278 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | N/A | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | N/A | $331 |
| Dental Filling - White (Resin): One Surface, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | N/A | $278 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | N/A | $404 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $294 | N/A | $294 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | N/A | $331 |
| Fluoride - Topical Application | $48 | N/A | $48 |
| Maintenance Therapy - Periodontal | $196 | N/A | $196 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $174 | N/A | $174 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $368 | N/A | $368 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | N/A | $113 |
| Root Canal - Anterior Tooth | $1,051 | N/A | $1,051 |
| Root Canal - Bicuspid Tooth | $1,203 | N/A | $1,203 |
| Root Canal - Molar | $1,458 | N/A | $1,458 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | N/A | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | N/A | $284 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $247 | N/A | $247 |
| X-Ray - Four Images, Bitewings | $92 | N/A | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | N/A | $47 |
| X-Ray - Two Images, Bitewings | $63 | N/A | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | N/A | $163 |
