| Dental Cleaning - Child | $100 | N/A | $100 |
| Dental Exam - Comprehensive | $131 | N/A | $131 |
| Dental Exam - Periodic, Established Patient | $68 | N/A | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | N/A | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | N/A | $404 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | N/A | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | N/A | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | N/A | $223 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | N/A | $404 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | N/A | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | N/A | $315 |
| Fluoride - Topical Application | $42 | N/A | $42 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | N/A | $110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | N/A | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | N/A | $231 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | N/A | $42 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | N/A | $168 |
