|
Diagnostic
|
| Code |
Dental Procedure |
Fee |
| 0110 |
Initial Oral Exam |
$15.00 |
| 0120 |
Periodic Oral Exam |
$10.00 |
| 0210 |
Adult Complete Mouth Radiographic Survey |
$30.00 |
| 0217 |
Child Complete Mouth Radiographic Survey |
$25.00 |
| 0330 |
Panoramic Radiograhic (Adult or Child) |
$30.00 |
| 0220 |
Periapical - Single First Film |
$ 6.00 |
| 0230 |
Periapical - Each Additional Film |
$ 6.00 |
| 0272 |
Bitewings - 2 Films |
$12.00 |
| 0274 |
Bitewings - 4 Films |
$17.00 |
|
Preventive
|
| 1110 |
Adult Prophylaxis (12 teeth or less $10.00 Discount) |
$20.00 |
| 1120 |
Child Prophylaxis (up to 12 years) |
$20.00 |
| 0120 |
Fluoride Treatment |
$ 6.00 |
| 1351 |
Pit and Fissure Sealants (per tooth) |
$ 6.00 |
| 1350 |
Pit and Fissure Sealants (per quadrants) |
$18.00 |
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