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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