|
ADA CODE |
DESCRIPTION |
HCC FEE |
|
|
DIAGNOSTIC |
|
|
D0150 |
Exam (New Patient or Established Patient) |
$10 |
|
D0210 |
FMX complete series |
$35 |
|
D0220 |
Periapical Radiograph (first PA film) |
$2 |
|
D0230 |
Periapical (each additional radiograph) |
$2 |
|
D0240 |
Occlusal Radiograph |
$5 |
|
D0270 |
BWX single film |
$2 |
|
D0272 |
BWX two films |
$4 |
|
D0274 |
BWX four films |
$8 |
|
D0330 |
Panoramic Image |
$40 |
|
|
Preventative Treatment |
|
|
D1110 |
Prophylaxis-Adult |
$30 |
|
D1120 |
Prophylaxis-Child |
$25 |
|
D1206 |
Topical Application of Fluoride Varnish |
$10 |
|
D1310 |
Nutritional Analysis |
$0 |
|
D1320 |
Tobacco Analysis (Cessation) |
$0 |
|
D1351 |
Sealant (per tooth) |
$5 |
|
|
Periodontics |
|
|
D4341 |
Periodontal Scaling and Root Planing-4 or more teeth per quadrant |
$50/quad |
|
D4342 |
Periodontal Scaling and Root Planing-1-3 teeth per quadrant |
$40/quad |
|
D4910 |
Periodontal Maintenance |
$30 |
|
|
Other |
|
|
|
Whitening Trays with 4 syringes of solution (10%, 15% or 35%) |
$65 |
|
|
4 syringes of whitening solution (10%, 15% or 35%) |
$45 |
|
D9940 |
Night Guard |
$30 |
|
D9630 |
Peridex 16 oz. bottle |
$12 |
|
D9630 |
Periomed |
$12 |
|
D9630 |
Clinipro 5000 |
$10 |
This educational facility provides preventive care only. An appointment is necessary and each appointment lasts 3.5 hours. Additional appointments may be necessary to complete treatment. The clinic does not accept cash or insurance. Forms of payment are checks, Visa, MasterCard, American Express and Discover credit/debit cards.
Please call 813.253.7527 to schedule an appointment.