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Sample Schedule of Fees

Code

Procedure Description

 Fee

0120 Oral Evaluation $32
0274 Bitewing X-rays (four films) $39
1110 Cleaning (adult) $69
1203 Topical application of fluoride (child) $24
1351 Sealant (per tooth) $31
2140 Amalgam Filling – One surface $89
2150 Amalgam Filling – Two surfaces $109
2330 Resin Filling – One surface (anterior teeth) $98
2331 Resin Filling – Two surfaces (anterior teeth) $121
2391 Resin Filling – One surface (posterior teeth) $115
2392 Resin Filling – Two surfaces (posterior teeth) $160
2750 Crown – Porcelain fused to high noble metal $801
2790 Crown – Full cast high noble metal $809
3320
Root Canal – Bicuspid (excluding final restoration)
$515
3330 Root Canal – Molar (excluding final restoration) $693
4341 Periodontal Scaling and Root Planing (four or more teeth per quadrant) $165
4910 Periodontal $95
   

Maintenance

5110 Complete Denture – Maxillary $1146
5214 Mandibular Partial Denture – Cast metal framework with resin denture bases $1071
6240 Pontic – Porcelain fused to high noble metal $738
6750 Crown – Porcelain fused to high noble metal $801
7140 Extraction (Erupted tooth or exposed root) $84
7210 Surgical removal of erupted tooth $154
8080 Comprehensive orthodontic treatment of the adolescent dentition $5058
9110 Palliative (Emergency) $87
    

Treatment of Dental Pain

6010/6059 Implant (body/crown) $1623/
$1133

 

 

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