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Sample Schedule of Fees
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
Learn more about Delta Dental Patient Direct:
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