GQE-120617-721abb8884

6 Dec 2017
# Item Codes and Description Quantity Price
1 Comprehensive exam and X-rays
  • d-011: Comprehensive oral examination
  • d-022: Intraoral periapical or bitweing radiograph – per exposure
  • d-022a: Step down fee for additional radiographs on same day(limit 5)
  • d-072:

    Photographic records – intraoral

  • d-073: Photographic records – extraoral
  • d-131: Dietary analysis and advice
  • d-141: Oral Hygiene instruction
1x(167.00)
  • 1x(57.00)
  • 1x(44.00)
  • 1x(0.00)
  • 1x(33.00)
  • 1x(33.00)
  • 1x(0.00)
  • 1x(0.00)
167.00
2 OPG and CBCT Analysis
  • d-015: Consultation – extended
  • d-037: Panoramic radiograph – per exposure
  • d-087: Conebeam volumentric tomography analysis and / or interpretation – small field of view (less than one complete dental arch)
1x(187.00)
  • 1x(84.00)
  • 1x(103.00)
  • 1x(0.00)
187.00
3 Periodic Examination
  • d-012: Periodic oral examination
  • d-114: Removal of calculus – first appointment
  • d-115: Removal of calculus – subsequent appointment
  • d-121: Topical application of remineralizing and/or cariostatic agents, one treatment
1x(253.00)
  • 1x(47.00)
  • 1x(105.00)
  • 1x(68.00)
  • 1x(33.00)
253.00
4 d-378
  • d-378: Surgical removal of foreign body
1x(138.00)
  • 1x(138.00)
138.00
Sub Total (A): 745.00
Cover Payout (D): 700.00
Gap Total (Est.): (C – D) 45.00

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