2011 Sample of UCR Fees Tel: (877) 878-3384 454-2928
Tel: (877) 878-3384 Fax: (415) 454-2928 [email protected] www.directdentalplans.com 2011 Sample of UCR Fees Below is a listing of 10 common dental procedures and the approximate 90% Usual, Customary and Reasonable Fees (UCR) allowed. These fees will vary by the zip code of the treating dental office and by date of service and are shown to provide a basis for appropriate fees in a given geographical area. Los Angeles, CA 90049 Code Procedure 90% Sample Fee 0120 Periodic Exam $60 0274 4 Bitewing Xrays $78 1110 Adult Prophylaxis (cleaning) $110 2140 1 surface Amalgam Filling (silver) $166 2330 1 surface composite – front tooth $195 2391 1 surface composite –back tooth $216 2750 Porcelain & Gold Crown $1326 3330 Molar Root Canal $1209 4341 Periodontal Scale/Root Plane (per quadrant) $303 0210 Full Mouth Xrays $158 San Francisco, CA 94117 Code Procedure 90% Sample Fee 0120 Periodic Exam $61 0274 4 Bitewing Xrays $79 1110 Adult Prophylaxis (cleaning) $112 2140 1 surface Amalgam Filling (silver) $170 2330 1 surface composite – front tooth $199 2391 1 surface composite –back tooth $220 2750 Porcelain & Gold Crown $1354 3330 Molar Root Canal $1234 4341 Periodontal Scale/Root Plane (per quadrant) $310 0210 Full Mouth Xrays $161 These fees are approximate and are not intended to establish the cost of dental treatment in any individual dental office. PO Box 2667 San Anselmo, CA 94979 www.directdentalplans.com
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