| Dental Cleaning - Adult | $105 | N/A | $105 |
| Dental Cleaning - Child | $84 | N/A | $84 |
| Dental Exam - Comprehensive | $96 | N/A | $96 |
| Dental Exam - Periodic, Established Patient | $53 | N/A | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | N/A | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $311 | N/A | $311 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | N/A | $245 |
| Dental Filling - White (Resin): One Surface, Posterior | $156 | N/A | $156 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | N/A | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $228 | N/A | $228 |
| Flouride - Topical Varnish Application | $58 | N/A | $58 |
| Fluoride - Topical Application | $47 | N/A | $47 |
| Maintenance Therapy - Periodontal | $210 | N/A | $210 |
| Tooth Extraction - Elevation and/or Forceps Removal | $156 | N/A | $156 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | N/A | $21 |
| X-Ray - Complete Intraoral Series | $161 | N/A | $161 |
| X-Ray - Four Images, Bitewings | $68 | N/A | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | N/A | $30 |
| X-Ray - Two Images, Bitewings | $51 | N/A | $51 |
