| Code |
Description |
Fee |
| 0120 |
Recall Exam |
$59 |
| 0140 |
Problem Focused Exam |
$84 |
| 0150 |
Comprehensive Exam |
$94 |
| 0210 |
Complete Series of Radiographs |
$148 |
| 0220 |
Periapical Radiograph |
$32 |
| 0230 |
Additional Periapical Radiograph |
$25 |
| 0274 |
Bite-wing Radiographs |
$71 |
| 1110 |
Prophylaxis Adult |
$105 |
| 1120 |
Prophylaxis Child |
$78 |
| 1206 |
Fluoride Varnish |
$47 |
| 1351 |
Sealants |
$59 |
| 2391 |
Surface Composite Resin / One Surface |
$198 |
| 2392 |
Surface Composite Resin / Two Surfaces |
$252 |
| 2740 |
All Porcelain Crown |
$1210 |
| 2950 |
Build-up Restoration |
$289 |
