Please list your standard fee for all service you actually bill the patient at a first time visit. For example, if you take a pano and an FMX but only bill the patient for one, please enter "$0" for the service you do not charge. If you do not usually perform the listed service, please check the box "N/A" instead of adding a dollar amount. You are able to add additional services and add your comments if you have additional information we should know.
New Patient Visit
6 Month Recall Visit
3rd Visit (1st Visit of the Second Year)