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Home My WebLink AboutC.054.93010_0525I Notes: Medicaid reimbursements are based on an updated list as of August 29, 200 . In-house computer system will write a discount allowance for any amount not covered by Medicaid and the patient will not be required to pay the difference. Cdt 3 Codes Descriptions ICHD Fee 117.00 115.00 D2386 Resin 2 Surface Perm 95.00 83.00 D2381 Resin 2 Surface Prim 148.00 143:20 D2387 Resin 3+ Surface Perm 167.00 68.50 D2336 Resin Crown - Prim. 59.00 19.00 D2940 Sedative Filling 103.00 83.00 D3220 Pulpotomy - Excl. Rest 141,00 115.00 D2930 SSC - Primary 174.00 173.00 D2931 SSC - Permanent 100.00 78.00 D2950 Crown Buildup 21.20 20.20 D2951 Pin Placement 139.00 60.57 D2970 Temporary Crown 35.00 16.00 D3110 Pulp Cap Direct 369.00 185.99 D3310 RCT- Anterior 405.00 405.00 D3330 RCT Molar 76.00 56.00 D7110 Ext. -Primary & Perm 76.00 56.00 D7120 Ext. - Each Additional Tooth 136.00 58.00 D7210 Surg. Ext. - Erupted 97.00 64.00 D7220 Soft Tis. Impact 130.00 90.82 D7230 Partial Bony Impact 250.00 121.27 D7240 Bony Impact 300.00 151.60 D7241 Bony Impact w/compl. 120.00 52.86 D7250 Resid. Roots - Unerupted 90.00 19.00 D7510 I &D Intra Oral 35.00 23.00 D9110 Emerg. Pallative Tx. 39.00 26.00 D9230 Analgesia 4$.00 13.22 D9610 Drug Inject. 26,00 16.00 D9630 Other Drug/Med, Notes: Medicaid reimbursements are based on an updated list as of August 29, 200 . In-house computer system will write a discount allowance for any amount not covered by Medicaid and the patient will not be required to pay the difference. Cdt 3 Codes Descriptions ICHD Fee D3351 Recalcification - Initial Visit D3352 Recalcification - Interim $125 500 Medication Replacement D3353 Recalcification -Final Visit $200 50 with Root Canal Therapy $60 D2920 Recement Crown $76 Extraction - Each Additional D7120 Tooth 50 ENVIRONMENTAL HEALTH 11 DIVISION User Fee Schedule Fiscal Year 2001-2002 Septic System Permit Type I or 1I System Type III System Type IV -VI System Septic System Repair Permit Relayout of Septic System Permit: Limited Comprehensive Existing System Inspection Installer Fee For Uncancelled Appointment Medicaid $103.33 $82.66 $154.99 19.00 Was $56.00 Now $57.00 FY'00-`01 FY'01-`02 $175 $175 300 300 500 500 No charge No charge 50 50 Full Permit Fee Full Permit Fee 50 50 50 50 11