| Dental Cleaning - Adult | $116 | N/A | $116 |
| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Periodic, Established Patient | $58 | N/A | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $172 | N/A | $172 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $265 | N/A | $265 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $216 | N/A | $216 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | N/A | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | N/A | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | N/A | $408 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | N/A | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | N/A | $314 |
| Fluoride - Topical Application | $51 | N/A | $51 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | N/A | $47 |
| X-Ray - Complete Intraoral Series | $171 | N/A | $171 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | N/A | $39 |
| X-Ray - Two Images, Bitewings | $59 | N/A | $59 |
