| Dental Cleaning - Adult | $135 | N/A | $135 |
| Dental Cleaning - Child | $99 | N/A | $99 |
| Dental Exam - Comprehensive | $125 | N/A | $125 |
| Dental Exam - Periodic, Established Patient | $61 | N/A | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $261 | N/A | $261 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | N/A | $415 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $335 | N/A | $335 |
| Dental Filling - White (Resin): One Surface, Anterior | $251 | N/A | $251 |
| Dental Filling - White (Resin): One Surface, Posterior | $261 | N/A | $261 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | N/A | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | N/A | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $335 | N/A | $335 |
| Flouride - Topical Varnish Application | $46 | N/A | $46 |
| Maintenance Therapy - Periodontal | $207 | N/A | $207 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $520 | N/A | $520 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | N/A | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $272 | N/A | $272 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | N/A | $32 |
| X-Ray - Complete Intraoral Series | $188 | N/A | $188 |
| X-Ray - Four Images, Bitewings | $84 | N/A | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | N/A | $41 |
| X-Ray - Two Images, Bitewings | $65 | N/A | $65 |
