| Less than 18 months |
Greater than 18 months and less than 36 months |
Greater than 36 months and less than 72 months |
| D0145 Oral evaluation patient under 3 |
$31.27 |
D0145 Oral evaluation patient under 3 |
$31.27 |
D0150 Comprehensive oral evaluation |
$31.27 |
| D0425 Caries risk assessment (CRA) |
$40.65 |
D0425 Caries risk assessment (CRA) |
$40.65 |
D1120 Child prophylaxis |
$31.27 |
| D1206 Fluoride varnish |
$18.76 |
D1206 Fluoride varnish |
$18.76 |
D1206 Fluoride varnish |
$18.76 |
| D1310 Nutritional counseling |
$37.52 |
D1310 Nutritional counseling |
$37.52 |
D1310 Nutritional counseling |
$37.52 |
| D1330 Oral hygiene instructions |
$21.89 |
|
|
|
|
| Total |
$150.09 |
Total |
$128.20 |
Total |
$118.82 |
| CRA = “high risk” then the child may be seen up to 6 times per year using same codes |
CRA = “high risk” then child may be seen up to 6 times per year using same codes |
CRA = any risk category may be seen up to 3 times per year using same codes |
