| Dental Cleaning - Adult | $119 | N/A | $119 |
| Dental Cleaning - Child | $105 | N/A | $105 |
| Dental Exam - Comprehensive | $113 | N/A | $113 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $235 | N/A | $235 |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | N/A | $235 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | N/A | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | N/A | $300 |
| Flouride - Topical Varnish Application | $60 | N/A | $60 |
| Maintenance Therapy - Periodontal | $176 | N/A | $176 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $329 | N/A | $329 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | N/A | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | N/A | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | N/A | $240 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | N/A | $33 |
| X-Ray - Complete Intraoral Series | $172 | N/A | $172 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | N/A | $38 |
| X-Ray - Two Images, Bitewings | $61 | N/A | $61 |
