| Dental Cleaning - Adult | $89 | N/A | $89 |
| Dental Cleaning - Child | $152 | N/A | $152 |
| Dental Exam - Comprehensive | $81 | N/A | $81 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $167 | N/A | $167 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $473 | N/A | $473 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $200 | N/A | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $267 | N/A | $267 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $257 | N/A | $257 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $168 | N/A | $168 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $228 | N/A | $228 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | N/A | $17 |
| X-Ray - Complete Intraoral Series | $221 | N/A | $221 |
| X-Ray - Four Images, Bitewings | $99 | N/A | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $23 | N/A | $23 |
| X-Ray - Two Images, Bitewings | $53 | N/A | $53 |
