Diagnostic Records Fees Diagnostic Records Fees Dr. Falk MAY request that the following diagnostic records be taken to better formulate a specific treatment recommendation and full treatment plan. • Panoramic X-Ray – $105.00 • Cephalometric X-Ray – $105.00 • Study Impressions/Models and/or a Digital Scan – $135.00 If requested, will ask permission before any are taken. If you have dental/orthodontic insurance coverage, our office will submit a claim for these services. You will be financially responsible for any balance after insurance has been received. If you decide to pursue orthodontic treatment in our office, any payments received from your insurance carrier will be applied to your treatment fee. I understand/agree if these procedures are completed, I/we am/are financially responsible for these services. Date* Month Day Year Patient Name* Responsible Party Name* Responsible Party Signature* Reset signature Signature locked. Reset to sign again Relationship to Patient* ShareTweetSharePin0 Shares
