UMB Fee Schedule 2016/2017
| Service Type |
ADA/Axium Code |
Description |
Fee |
| Diagnostics |
D0210 |
Intraoral-complete series |
130 |
| Diagnostics |
D0220 |
Intraoral-periapical 1st film |
27 |
| Diagnostics |
D0230 |
Intraoral-periapical add film |
23 |
| Diagnostics |
D0240 |
Intraoral - occlusal film |
37 |
| Diagnostics |
D0270 |
Bitewing - single film |
27 |
| Diagnostics |
D0272 |
Bitewing - 2 films |
33 |
| Diagnostics |
D0273 |
Bitewing – 3 films |
39 |
| Diagnostics |
D0274 |
Bitewing - 4 films |
45 |
| Diagnostics |
D0277 |
Vertical Bitewings 7-8 films |
85 |
| Diagnostics |
D0330 |
Panoramic film |
85 |
| Diagnostics |
D0110.1 |
Medical History Analysis |
0 |
| Diagnostics |
D0110.2 |
Soft Tissue Exam |
0 |
| Diagnostics |
D0110.3 |
Hygiene Assessment |
0 |
| Diagnostics |
D0120 |
Periodic oral evaluation |
35 |
| Diagnostics |
D0140 |
Limited oral eval-prob focused |
64 |
| Diagnostics |
D0145 |
Oral Eval.Patient Under 3yrs |
35 |
| Diagnostics |
D0150 |
Comprehensive oral evaluation |
69 |
| Preventative |
D1110 |
Prophy – adult |
66 |
| Preventative |
D1120 |
Prophy – child |
44 |
| Preventative |
D1208 |
Fluoride, topical |
25 |
| Preventative |
D1310 |
Nutritional counseling |
0 |
| Preventative |
D1320 |
Tobacco counseling |
0 |
| Preventative |
D1330 |
Oral hygiene instructions |
0 |
| Preventative |
D1351 |
Sealant - per tooth |
32 |
| Periodontics |
D4341 |
Scaling/root planing- 4 or more per Quad |
77 |
| Periodontics |
D4342 |
Scaling/root planing 1-3 teeth per Quad |
48 |
| Periodontics |
D4355 |
Full mouth debridement |
106 |
| Periodontics |
D4381 |
Antimicrobial Agent- per site |
68 |
| Periodontics |
D4910 |
Periodontal maintenance |
78 |
| Miscellaneous |
D9975 |
External bleaching* - per arch |
162 |
| Prevident 5000 Plus |
|
|
4 |
| MI Paste |
|
|
7.99 |
| Chlorhexidine |
Small Bottle |
|
3.50 |
| Chlorhexidine |
Large Bottle |
|
5.50 |
Updated 6/2016
*whitening refills are $35. and charged as an office visit THIS MUST BE DONE BY MIL BOYD or SHARON CHENOWITH ONLY