| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Exam - Comprehensive | $79 | N/A | $79 |
| Dental Exam - Periodic, Established Patient | $46 | N/A | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | N/A | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $284 | N/A | $284 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | N/A | $236 |
| Dental Filling - White (Resin): One Surface, Anterior | $152 | N/A | $152 |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | N/A | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | N/A | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | N/A | $27 |
| X-Ray - Complete Intraoral Series | $155 | N/A | $155 |
| X-Ray - Four Images, Bitewings | $82 | N/A | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $27 | N/A | $27 |
| X-Ray - Two Images, Bitewings | $55 | N/A | $55 |
