| Dental Cleaning - Adult | $110 | N/A | $110 |
| Dental Cleaning - Child | $89 | N/A | $89 |
| Dental Exam - Comprehensive | $95 | N/A | $95 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $378 | N/A | $378 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | N/A | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | N/A | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | N/A | $378 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | N/A | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | N/A | $273 |
| Fluoride - Topical Application | $43 | N/A | $43 |
| Maintenance Therapy - Periodontal | $158 | N/A | $158 |
| Oral Hygiene Instructions | $43 | N/A | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | N/A | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | N/A | $91 |
| Root Canal - Anterior Tooth | $945 | N/A | $945 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Complete Intraoral Series | $147 | N/A | $147 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
