Procedure	ADA Code	Med Code	Cost
Detailed Focused Evaluation-CFP	0160	99204	included
FMX Digital Radiographs - All	0210	70320	included
Orofacial and Posture Images	0350	99070	included
3D Cone Beam CT Scan & Review	0360	70486	included
Oral Cancer Screening ID	0431	02431	included
Diagnostic Casts	0470	99070	included
Computerized Jaw Tracking (JT)	0999JT	97750	included
Computerized Joint Survey (JVA)	0999JVA	77077	included
Neurologic Testing	0999NT	95831	included
Pharyngometer (Airway)	0999PR	92520	included

3. Final Consultation Appointment (1 hour) - 1 wk after records

Both the patient, patient’s spouse (if applicable), and the responsible party(s) should attend this final consultation. Atthis time, your orofacial health will be discussed, conditions will be explained, and the proposed treatment plan willbe outlined.

4. Insertion of oral sleep appliance (30 minutes) - 2 wks after final consult

5. Up to 5 (five) follow up visits and modifications (30-60 minutes each) - as needed

6. Take-home sleep study to assure effectiveness of oral sleep appliance (overnight)

Payment of Fees

Payment for treatment is due at the time of service. Medical and/or dental insurance may reimburse you for some or all of our services. It is YOUR responsibility to obtain any reimbursement. At the conclusion of treatment, a superbill that you can send to your insurance company will be provided as a courtesy.

By signing below, I attest that I understand and agreeto the above-listed procedures and associated fees.