| Dental Cleaning - Adult | $126 | N/A | $126 |
| Dental Cleaning - Child | $107 | N/A | $107 |
| Dental Exam - Comprehensive | $116 | N/A | $116 |
| Dental Exam - Periodic, Established Patient | $66 | N/A | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | N/A | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | N/A | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | N/A | $308 |
| Dental Filling - White (Resin): One Surface, Anterior | $190 | N/A | $190 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | N/A | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $390 | N/A | $390 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | N/A | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | N/A | $308 |
| Flouride - Topical Varnish Application | $51 | N/A | $51 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| Oral Hygiene Instructions | $46 | N/A | $46 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $276 | N/A | $276 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $88 | N/A | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | N/A | $40 |
