| Dental Cleaning - Adult | $131 | N/A | $131 |
| Dental Cleaning - Child | $95 | N/A | $95 |
| Dental Exam - Comprehensive | $158 | N/A | $158 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | N/A | $394 |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | N/A | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | N/A | $252 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $386 | N/A | $386 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $291 | N/A | $291 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | N/A | $331 |
| Fluoride - Topical Application | $55 | N/A | $55 |
| Maintenance Therapy - Periodontal | $210 | N/A | $210 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | N/A | $68 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | N/A | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | N/A | $103 |
| Root Canal - Molar | $2,189 | N/A | $2,189 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | N/A | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | N/A | $34 |
| X-Ray - Four Images, Bitewings | $86 | N/A | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $268 | N/A | $268 |
