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1 <br />i COX J r1. <br />L P.'.GE ~JO <br />Lee-Chatham Children's Dental Clinic <br />Fee Schedule <br />s <br />CJ <br />Procedure Code <br />Description <br />Fee <br />0120 <br />Periodic Oral Evaluation <br />28.00 <br />0140 <br />Limited Oral Evaluation <br />38.00 <br />0150 <br />Comprehensive Oral Evaluation <br />38.00 <br />0160 <br />Detailed & Extensive Evaluation <br />57.00 <br />0210 <br />Intraoral Including Bitewin s <br />63.00 <br />0220 <br />Intraoral Peria ical I" Film <br />16.00 <br />0230 <br />Intraoral Peria ical, Add'I Film <br />10.00 <br />0240 <br />Intraoral Occlusal Film <br />19.00 <br />0250 <br />Extraoral 15' Film <br />32.00 <br />0260 <br />Extraoral, Add] Film <br />16.00 <br />0270 <br />Bitewin Single Film <br />16.00 <br />0272 <br />Bitewin 2 Films <br />19.00 <br />0274 <br />Bitewin 4 Films <br />33.00 <br />0330 <br />Panoramic Film <br />50.00 <br />0340 <br />Ce halometric Film <br />63.00 <br />0470 <br />Diagnostic Casts <br />41.00 <br />1110 <br />Prophylaxis-Adult <br />46.00 <br />1120 <br />Prophylaxis-Child <br />30.00 <br />1201 <br />Prophylaxis-Child w/ Fluoride <br />41.00 <br />1203 <br />Child Fluoride Application <br />19.00 <br />1205 <br />Pro h -Adult w/ Fluoride <br />61.00 <br />1351 <br />Sealant per Tooth <br />32.00 <br />1510 <br />Space Maintainer Fixed Unilateral <br />129.00 <br />1515 <br />Space Maintainer Fixed Bilateral <br />193.00 <br />2110 <br />Amalgam 1 Surf. Prima <br />58.00 <br />2120 <br />Amalgam 2 Surf. Primary <br />81.00 <br />2130 <br />Amalgam 3 Surf. Prima <br />102.00 <br />2131 <br />Amalgam 4+ Surf. Prima <br />115.00 <br />2140 <br />Amalgam 1 Surf. Permanent <br />66.00 <br />2150 <br />Amalgam 2 Surf. Permanent <br />81.00 <br />