| Amalgam 4 or > surfaces perm (D2161) |
$50.40 |
$126 |
0.1× |
| Amalgam one surface permanen (D2140) |
$32.80 |
$82 |
0.0× |
| Amalgam three surfaces perma (D2160) |
$42.80 |
$107 |
0.1× |
| Amalgam two surfaces permane (D2150) |
$37.20 |
$93 |
0.0× |
| Ant resin-based cmpst crown (D2390) |
$42 |
$105 |
0.1× |
| Bitewings - three images (D0273) |
$22 |
$55 |
0.1× |
| Bitewings four images (D0274) |
$26 |
$65 |
0.1× |
| Ca screen;pelvic/breast exam (G0101) |
$47.60 |
$119 |
0.4× |
| Comp periodontal evaluation (D0180) |
$66 |
$165 |
0.4× |
| Comprehensve oral evaluation (D0150) |
$80 |
$200 |
0.5× |
| Dental bitewing single image (D0270) |
$10 |
$25 |
0.1× |
| Dental bitewings two images (D0272) |
$20 |
$50 |
0.2× |
| Dental prophylaxis adult (D1110) |
$80 |
$200 |
0.5× |
| Drug test def 1-7 classes (G0480) |
$34 |
$85 |
0.3× |
| Extensv oral eval prob focus (D0160) |
$80 |
$200 |
0.5× |
| Extraction erupted tooth/exr (D7140) |
$32 |
$80 |
0.0× |
| Full mouth debridement (D4355) |
$40 |
$100 |
0.0× |
| I&d absc intraoral soft tiss (D7510) |
$45.60 |
$114 |
0.1× |
| I&d abscess extraoral (D7520) |
$164.40 |
$411 |
0.2× |
| Impact tooth rem bony w/comp (D7241) |
$136.80 |
$342 |
0.2× |
| Impact tooth remov comp bony (D7240) |
$100 |
$250 |
0.1× |
| Impact tooth remov part bony (D7230) |
$92 |
$230 |
0.1× |
| Impact tooth remov soft tiss (D7220) |
$80 |
$200 |
0.1× |
| Intraor comprehensive series (D0210) |
$40 |
$100 |
0.1× |
| Intraoral occlusal film (D0240) |
$10 |
$25 |
0.1× |
| Intraoral periapical first (D0220) |
$10 |
$25 |
0.1× |
| Limit oral eval problm focus (D0140) |
$72 |
$180 |
0.4× |
| Obtaining screen pap smear (Q0091) |
$55.20 |
$138 |
1.5× |
| Periodic oral evaluation (D0120) |
$70 |
$175 |
0.4× |
| Periodontal maint procedures (D4910) |
$32.80 |
$82 |
0.0× |
| Periodontal scaling & root (D4341) |
$55.20 |
$138 |
0.1× |
| Periodontal scaling 1-3teeth (D4342) |
$40 |
$100 |
0.0× |
| Place direct restoration (D2940) |
$28.80 |
$72 |
0.0× |
| Post 1 srfc resinbased cmpst (D2391) |
$40.40 |
$101 |
0.0× |
| Post 2 srfc resinbased cmpst (D2392) |
$52.40 |
$131 |
0.1× |
| Post 3 srfc resinbased cmpst (D2393) |
$63.60 |
$159 |
0.1× |
| Post >=4srfc resinbase cmpst (D2394) |
$71.60 |
$179 |
0.1× |
| Prefab stnlss steel crown pe (D2931) |
$50 |
$125 |
0.1× |
Psa screening (G0103)
range across 3 matching MRF lines |
$9.50–$75.20 |
$23.75–$188 |
varies |
| Re-cement or re-bond crown (D2920) |
$28 |
$70 |
0.0× |
| Re-eval,est pt,problem focus (D0170) |
$70 |
$175 |
0.4× |
| Recement inlay onlay or part (D2910) |
$26 |
$65 |
0.0× |
| Rem imp tooth w mucoper flp (D7210) |
$64 |
$160 |
0.0× |
| Resin 4/> surf or w incis an (D2335) |
$60 |
$150 |
0.1× |
| Resin one surface-anterior (D2330) |
$40 |
$100 |
0.0× |
| Resin three surfaces-anterio (D2332) |
$53.60 |
$134 |
0.1× |
| Resin two surfaces-anterior (D2331) |
$44 |
$110 |
0.1× |
| Therapeutic pulpotomy (D3220) |
$60 |
$150 |
0.1× |
| Tomosynthesis, mammo (G0279) |
$101.60 |
$254 |
8.0× |