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235 South 400 East, Bountiful, Utah, 84010

(801) 298-1812

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Limited Records

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New Patient Diagnostic Records

  • "Limited" Diagnostic Records

  • Diagnosis is the key to any successful treatment. As you are presenting with no craniofacial or sleep disorders of which you are aware, our records appointment will be "limited" to the following records. If it is determined that there are underlying disorders and/or conditions beyond which the "limited" records will allow us to see, other records/tests may be indicated and recommended.

    1. Records Appointment

    Information is gathered in order to make a thorough assessment and diagnosis. This includes:

    ProcedureADA CodeMed CodeCost
    Comprehensive Oral Exam015099203$75.00
    FMX Digital Radiographs - All021070320$101.00
    Orofacial and Posture Images035099070$63.00
    Nutritional ScanNS$25.00
    Diagnostic Casts (If Necessary)047099070$75.00
    Oral Cancer Phosphorescence048202431$25.00
    3D Digital Panoramic Image036770355$101.00
    Vitamin D TestVITD$35.00
    Heart Rate VariabilityHRV$25.00
    A1C TESTA1C$25.00
    MEAS TestMEAS$25.00
    Total Diagnostic Fees: $575
    2. Consultation Appointment  

    Should more than 1-2 simple fillings be required to restore your orofacial system to health, Dr.Wall will analyze your records and create a customized care plan. The fee listed is for care plan creation and accompanying consultation appointment.


    COST $205

    Payment of Fees

    If you have dental insurance, some of these fees may be reimbursable. Regardless of insurance coverage, however, payment for services rendered are due at the time of service. I understand that there is a NON-REFUNDABLE $200 deposit to reserve a diagnostic appointment.

    By signing below, I attest that I understand and agree to the above-listed procedures and associated fees.
  • MM slash DD slash YYYY

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

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(801) 298-1812
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