| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $74 | N/A | $74 |
| Dental Exam - Comprehensive | $91 | N/A | $91 |
| Dental Exam - Periodic, Established Patient | $57 | N/A | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | N/A | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $301 | N/A | $301 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $246 | N/A | $246 |
| Dental Filling - White (Resin): One Surface, Anterior | $174 | N/A | $174 |
| Dental Filling - White (Resin): One Surface, Posterior | $206 | N/A | $206 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $301 | N/A | $301 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | N/A | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $246 | N/A | $246 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $131 | N/A | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | N/A | $263 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Complete Intraoral Series | $161 | N/A | $161 |
| X-Ray - Four Images, Bitewings | $74 | N/A | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | N/A | $26 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | N/A | $126 |
