| Dental Cleaning - Adult | $100 | N/A | $100 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $92 | N/A | $92 |
| Dental Exam - Periodic, Established Patient | $42 | N/A | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | N/A | $184 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | N/A | $257 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | N/A | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | N/A | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | N/A | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | N/A | $257 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | N/A | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | N/A | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | N/A | $26 |
| X-Ray - Complete Intraoral Series | $142 | N/A | $142 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | N/A | $32 |
| X-Ray - Two Images, Bitewings | $47 | N/A | $47 |
