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Sample Schedule of Fees

Code

Procedure Description

 Fee

0120 Oral Evaluation $33
0274
Bitewing images (four radiographic images)
$40
1110 Cleaning (adult) $70
1203 Topical application of fluoride (child) $25
1351 Sealant (per tooth) $32
2140 Amalgam Filling – One surface $90
2150 Amalgam Filling – Two surfaces $111
2330 Resin Filling – One surface (anterior teeth) $100
2331 Resin Filling – Two surfaces (anterior teeth) $124
2391 Resin Filling – One surface (posterior teeth) $117
2392 Resin Filling – Two surfaces (posterior teeth) $162
2750 Crown – Porcelain fused to high noble metal $815
2790 Crown – Full cast high noble metal $809
3320
Root Canal – Bicuspid (excluding final restoration)
$528
3330 Root Canal – Molar (excluding final restoration) $711
4341 Periodontal Scaling and Root Planing (four or more teeth per quadrant) $167
4910 Periodontal Maintenance $96
   

Maintenance

5110 Complete Denture – Maxillary $1146
5214 Mandibular Partial Denture – Cast metal framework with resin denture bases $1100
6240 Pontic – Porcelain fused to high noble metal $757
6750 Crown – Porcelain fused to high noble metal $815
7140 Extraction (Erupted tooth or exposed root) $86
7210 Surgical removal of erupted tooth $158
8080 Comprehensive orthodontic treatment of the adolescent dentition $5058
9110 Palliative (Emergency) $88
    

Treatment of Dental Pain

6010/6059 Implant (body/crown) $1623/
$1185

 

 





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