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Home My WebLink AboutC.054.93011_0781 (2)5. Request from the Health Department for Approval of the FY 2005-06 Fee Schedule: At the briefing session, Health Director Donna Campbell requested approval of the following fees for the upcoming year. Allied Health Dental Fees FEES Eff. Date FEES CDT CODE SERVICE DESCRIPTION FY 2004-2005 5/2/2005 FY 2005-2006 D0120 Recall exam $29.00 $34.00 $34.00 D0140 Emergency exam $39.00 $48.00 $48.00 D0150 Initial oral exam $50.00 $ 60.00 $60.00 D0210 Complete series x-rays $76.00 $ 87.00 $87.00 D0220 Periapical x-ray 514.00 $19.00 $19.00 D0230 Periapical - two or more $12.00 $16.00 $16.00 D0240 Occlusal P.A. $24.00 $29.00 $29.00 D0270 Bitewings - single film $12.00 $19.00 $19.00 D0272 Bitewings - x 2 $23.00 $31.00 $31.00 D0274 Bitewings - x 4 $42.00 $43.00 $43.00 D0330 Panorex x-rays $60.00 $76.00 $76.00 Dl 110 Prophy (adult) 13 & older $50.00 $63.00 $63.00 D1120 Prophy (child) age less than 13 $38.00 $46.00 $46.00 D1201 Prophy w/fluoride (child <13)$51.00 $65.00 $65.00 D1203 Prophy w/fluoride varnish (<13)$20.00 $26.00 $26.00 D1204 Floride varnish (13 - 20 yrs) $25.00 $26.00 $26.00 D1205 Prophy wlfluoride (adult 13>)$62.00 $62.00 $62.00 D1330 Oral Hyg. Under 3 years $25.00 $25.00 $25.00 D1351 Sealants $32.00 $37.00 $37.00 DI510 Space Minot. Fixed - Unilateral $209.00 $224.00 $224.00 D1515 Space Maint. Fixed - Bilateral $419.00 $425.00 $425.00 D1520 Remove Spc Maint. Unilateral $80.00 $150.00 $150.00 D1525 Remvl Spc Maint. Bilateral $85.00 $160.00 $160.00 D1550 Recement Space Maint $60.00 $60.00 $60.00 D2140 Amalgam I surf, -perm/primary $66.00 $88.00 $88.00 D2150 Amalgam 2surf. -pemdprimary $83.00 $114.00 $114.00 D2160 Amalgam 3 surf. - pemt/primary $102.00 $140.00 $140.00 D2161 Amalgam 4 surf. - perm/primary $124.00 $167.00 $167.00 D2330 Resin I surf. - anterior $78.00 $105.00 $105.00 D2331 Resin 2 surf. - anterior $95.00 $131.00 $131.00 D2332 Resin 3 surf. - anterior $120.00 $162.00 $162.00 D2335 Resin 4 surf. - anterior $141.00 $175.00 $175.00 D2390 Resin based composite crown anterior $167.00 $275.00 $275.00 D2391 Resin based composite I surface $80.00 $118.00 $118.00 D2392 Resin based composite 2 surfaces $120.00 $158.00 $158.00 D2393 Resin based composite 3 surfaces $160.00 $196.00 $196.00 D2394 Resin based composite 4 or more surfaces $190.00 $237.00 $237.00 D2920' Recement Crown $60.00 $75.00 $75.00 D2930 SSC - primary $145.00 $185.00 $185.00 D2931 SSC - permanent $174.00 $219.00 $219.00 D2940 Sedative filling $59.00 $72.00 $72.00 D2950 Crown build-up $100.00 $180.00 $180.00 D2951 Pin placement $22.00 $45.00 $45.00 D2970" Temporary crown $139.00 $220.00 $220.00 D3110' Pulp cap direct $35.00 $57.00 $57.00 D3220 Pulpotomy Excl. rest $103.00 $133.00 $133.00 D3310 RCT - anterior $369.00 $484.00 $484.00 D3330 RCT - molar $405.00 $700.00 $700.0 D3351 Recalcification - initial visit $174.00 $240.00 $240.00 D3352 Recal-tnterimmedication repicnmt.5125.00 $180.00 $180.00 D3353 Recalcification - final visit $200.00 $350.00 $350.00 D4210 Gingivectomy/Gingivoplasty$125.00 $420.00 $420.00 D4211 Gingitomy/gingiplsty1-3contusteth$115.00 $155.00 $155.00 D4240 Gingival flap proced. 4 or more $125.00 $490.00 $490.00 per quad D4241 Gingival flap proced 1-3 per $125.00 $420.00 $420.00 quad D4341 Root planning/scale 4 or more $141.00 $174.00 $174.00 D4342 Peridd scaling & root planning $110.00 $122.00 $122.00 1-3 D4355 Grossscale -perio $103.00 $129.00 $129.00 D4910 Periodontal maint. Treatment $77.00 $97.00 $97.00 D7111 "' Comnai Remnants -Deciduous Teeth $80.00 $97.00 $97.00 D7140 Ext erupted tooth or exposed root $80.00 $109.00 $109.00