Preventative
Periodontics
Imaging/Exam
Hygiene Other
Miscellaneous
100

Adult prophy

D1110

100

Quad Root Debridement (4+)

D4341

100

FMX

D0210

100

Occlusal Guard

D9940

100

1st PA

D0220

200

Child Prophy

D1120

200

Quad Root Debridement (1-3)

D4342

200

4 BWX

D0274

200

Bleach Trays

D9972

200

Intra-Oral Photos

D0350

300

Fluoride Varnish

D1206

300

Periodontal Maintenance

D4910

300

Pano

D0330

300

Nitrous

D9230

300

Limited Re-evaluation Post-Operative

D0171

400

Sealant

D1351

400

Gingival Irrigation

D4921

400

6 Month Checkup Exam

D0120

400

Oral Cancer Screening

D0431

400

Tobacco Counseling

D1320

500

Oral Hygiene Education

D1330

500

Antimicrobial Agents

D4381

500

New Patient Exam

D0150

500

Office Dispensing of Medicaments

-FL2, CHX, Antibiotics, Analgesics, MI Paste

D9630

500

Vertical BWX

D0277

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