Delta Dental Patient Direct
Sample Schedule Delta Dental Patient Direct® Discounted Fees - 2010
| 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 | $785 |
| 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 Maintenance | $95 |
| 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) treatment of dental pain | $87 |
| 6010/ 6059 |
Implant (body/crown) | $1623/ $1133 |