| Dental Cleaning - Adult | $127 | N/A | $127 |
| Dental Cleaning - Child | $116 | N/A | $116 |
| Dental Exam - Comprehensive | $210 | N/A | $210 |
| Dental Exam - Periodic, Established Patient | $56 | N/A | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | N/A | $228 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $436 | N/A | $436 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | N/A | $314 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $281 | N/A | $281 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | N/A | $269 |
| Flouride - Topical Varnish Application | $49 | N/A | $49 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $88 | N/A | $88 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | N/A | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | N/A | $37 |
| X-Ray - Four Images, Bitewings | $101 | N/A | $101 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | N/A | $37 |
| X-Ray - Two Images, Bitewings | $67 | N/A | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $167 | N/A | $167 |
