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NATIONFEESCHEDULEHASSELLCORRECTION - Copy

NATIONFEESCHEDULEHASSELLCORRECTION -

\ LISTING OF MAXIMUM ALLOWABLE CHARGES CODE DESCRIPTION USUAL PROMO PLAN* D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $62.00 $31.00 $26.00 D0140 LIMITED ORAL EVALUATION – PROBLEM FOCUSED $52.00 $39.00 $29.00 D0150 COMPREHENSIVE ORAL EVALUATION – NEW OR ESTABLISHED PATIENT $83.00 $47.00 $35.00 D0210 INTRAORAL – COMPLETE SERIES (INCLUDING BITEWINGS) $133.00 $88.00 $72.00 D0220 INTRAORAL – PERIAPICAL FIRST FILM $23.00 $16.00 $12.00 D0230 INTRAORAL – PERIAPICAL EACH ADDITIONAL FILM $16.00 $12.00 $10.00 D0270 BITEWING – SINGLE FILM $23.00 $15.00 $12.00 D0272 BITEWINGS – TWO FILMS $28.00 $25.00 $21.00 D0470 DIAGNOSTIC CASTS $53.00 $47.00 $27.00 D1110 PROPHYLAXIS – ADULT $68.00 $49.00 $29.00 D1120 PROPHYLAXIS – CHILD $58.00 $39.00 $29.00 D1203 TOPICAL APPLICATION OF FLUORIDE – CHILD $42.00 $25.00 $19.00 D1204 TOPICAL APPLICATION OF FLUORIDE – ADULT $42.00 $25.00 $19.00 D1330 ORAL HYGIENE INSTRUCTIONS $44.00 $25.00 $19.00 D1351 SEALANT – PER TOOTH $42.00 $28.00 $21.00 D2330 RESIN-BASED COMPOSITE – ONE SURFACE, ANTERIOR $132.00 $75.00 $65.00 D2331 RESIN-BASED COMPOSITE – TWO SURFACE, ANTERIOR $164.00 $106.00 $65.00 D2332 RESIN-BASED COMPOSITE – THREE SURFACE, ANTERIOR $191.00 $129.00 $95.00 D2335 RESIN-BASED COMPOSITE – FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE, (ANTERIOR) $219.00 $176.00 $110.00 D2391 RESIN-BASED COMPOSITE – ONE SURFACE, POSTERIOR $134.00 $90.00 $55.00

ZTS MEDIJA 3
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