| Dental Cleaning - Adult | $231 | N/A | $231 |
| Dental Cleaning - Child | $189 | N/A | $189 |
| Dental Exam - Comprehensive | $159 | N/A | $159 |
| Dental Exam - Periodic, Established Patient | $59 | N/A | $59 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | N/A | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): One Surface, Posterior | $250 | N/A | $250 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | N/A | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $313 | N/A | $313 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | N/A | $313 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Maintenance Therapy - Periodontal | $166 | N/A | $166 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $355 | N/A | $355 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $101 | N/A | $101 |
| Tooth Extraction - Elevation and/or Forceps Removal | $365 | N/A | $365 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $65 | N/A | $65 |
| X-Ray - Complete Intraoral Series | $230 | N/A | $230 |
| X-Ray - Four Images, Bitewings | $85 | N/A | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $69 | N/A | $69 |
| X-Ray - Two Images, Bitewings | $64 | N/A | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | N/A | $156 |
