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HomeMy WebLinkAboutC.054.93010_080519 FEES FY FEES FY CPT CODE SERVICE DESCRIPTION 2001-2002 2002-2003 97802 Nutrition Education Initial Assessment (15 min) $18.00 $18.00 97803 Nutrition Education Subseq. Assessment (15 min) $18.00 $18.00 Sliding fee scale utilized for non -Medicaid patients. D0120 Recall exam $29.00 $29.00 D0140 Emergency exam $39.00 $39.00 D0150 Initial oral exam $50.00 $50.00 D0210 Complete series x-rays $75.00 $75.00 D0220 Periapical x-ray $14.00 $14.00 D0230 Periapical - two or more $12.00 $12.00 D0240 Occlusal P.A. $24.00 $24.00 D0270 Bitewings - single film $12.00 $12.00 D0272 Bitewings - x 2 $23.00 $23.00 D0274 Bitewings - x 4 $4100 $42.00 D0330 Panorex x-rays $60.00 $60.00 DI 110 Prophy (adult) 13 & older $50.00 $50.00 DI 120 Prophy (child) age less than 13 $38.00 $38.00 D1201 Prophy w/fluoride (child <13) $51.00 $51.00 D1203 Prophy, w/fluoride varnish (<13) $20.00 $20.00 D1205 Prophy w/fluoride (adult 13>) $62.00 $62.00 D1351 Sealants $32.00 $32.00 D1510 SpaceMaint.Fixed- Unilateral $175.00 $175.00 D1515 SpaceMaint.Fixed- Bilateral $180.00 $180.00 D2110 Amalgam 1 surf. - primary teeth $60.00 $60.00 D2120 Amalgam 2 surf. - Primary teeth $81.00 $81.00 D2130 Amalgam 3 surf. - primary teeth $102.00 $102.00 D2131 Amalgam 4 surf. - primary teeth $115.00 $115.00 D2140 Amalgam 1 surf. - permanent $66.00 $66.00 D2150 Amalgam 2 surf. - permanent $83.00 $83.00 D2160 Amalgam 3 surf. - permanent $102.00 $102.00 D2161 Amalgam 4 surf. - permanent $124.00 $124.00 D2330 Resin 1 surf. - anterior $78.00 $78.00 D2331 Resin 2 surf. - anterior 95.00 95.00 D2332 Resin 3 surf. - anterior 120.00 120.00 D2335 Resin 4 surf. - anterior 141.00 141.00 D2336 Resin crown - primary 167.00 167.00 D2380 Resin I surf. - posterior primary 75.00 75.00 D2381 Resin 2 surf. - primary 95.00 98.00 D2385 Resin 2 surf. - posterior perman. 84.00 84.00 D2386 Resin 2 surf. - permanent 117.00 117.00 D2387 Resin 3+ surf. - permanent 150.00 150.00 D2920 Recement Crown 60.00 60.00 D2930 SSC - primary 141.00 141.00 D2931 SSC - permanent 174.00 174.00 D2940 Sedative filling 59.00 59.00 D2950 Crown build-up 100.00 100.00 D2951 Pin placement 21.20 22.00 D2970 Temporary crown 139.00 139.00 D3110 Pulp cap direct 35.00 35.00 D3220 Pulpotomy Excl. Rest 103.00 103.00 D3310 RCT -anterior 369.00 369.00 D3330 RCT -molar 405.00 405.00 D3351 Recalcification - initial visit 174.00 174.00 D3352 Recal -Interim medication replcmnt. 125.00 125.00 D3353 Recalcification - final visit 200.00 200.00 D4341 Root planning/scale (ea. Quad) 141.00 141.00 D4355 Gross scale - perio 103.00 103.00 D4910 Periodontal maint. Treatment 77.00 77.00 D7110 Ext. - primary & permanent 76.00 76.00 D7120 Ext. ea. Additional tooth 76.00 76.00 D7210 Surgical ext. - erupted 136.00 136.00 D7220 Soft tissue impact 97.00 97.00 D7230 Partial bony impact 130.00 130.00 D7240 Bony impact 250.00 250.00 D7241 Bony impact w/complications 300.00 300.00 D7250 Residual roots - unerupted 120.00 120.00 D7510 1 & D intra oral 90.00 90.00 D9110 Emergency palliative treatment 35.00 35.00 19