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Home My WebLink AboutC.054.93011_1234I unit = 15 minutes ALLIED HEALTH DENTAL FEES FY FEES FY FEES FY Proposed FEES CDTCODE SERVICE DESCRIPTION 20042005 2005-2006 2006-2007 00120 Recall exam $29.00 $34.00 S34.00 00140 Emergency exam $39.00 S48.00 548.00 00150 Initial oral exam 550.00 $60.00 560.00 00210 Complete series x-rays 576.00 S87.00 S87.00 00220 Periapical x-ray 514.00 $19.00 519.00 00230 Periapical - two or more S12.00 S16.00 $16.00 00240 Occlusal P.A. $24.00 529.00 529.00 00270 Bitewings - single film S12.00 S19.00 519.00 00272 Bitewings - x 2 523.00 $31.00 $31.00 00274 Bitewings - x 4 $42.00 $43.00 $43.00 00330 Panorex x-rays S60.00 $76.00 $76.00 01110 Prophy, (adult) 13 & older $50.00 $63.00 S63.00 01120 Prophy (child) age less than 13 538.00 546.00 546.00 01201 Prophy w/fluoride (child <13) S51.00 $65.00 S65.00 01203 Prophy, w/fluoride vamish « 13) S20.00 $26.00 526.00 01204 Floride varnish (13 - 20 yrs) $25.00 $26.00 $26.00 01205 Prophy w/fluoride (adult I3» $62.00 S62.00 S62.00 01330 Oral Hyg. Under 3 years 525.00 S25.00 S25.00 01351 Sealants $32.00 537.00 537.00 01510 Space Main!. Fixed - Unilateral 5209.00 5224.00 $224.00 01515 Space Main!. Fixed - Bilateral 5419.00 5425.00 5425.00 01520 Remove Spc Main!. Unilateral S80.00 S150.00 $150.00 01525 Remv1 Spc Main!. Bilateral $85.00 S160.00 5160.00 01550 Recement Space Main!. S60.00 560.00 $60.00 02140 Amalgam I surf. - perm/primary S66.00 S88.00 $88.00 02150 Amalgam 2 surf. - perm/primary S83.00 $114.00 $ 114.00 02160 Amalgam 3 surf. - perm/primary 5202.00 5140.00 $140.00 02161 Amalgam 4 surf - perm/primary S124.00 S167.00 S167.00 02330 Resin I surf. -anterior 578.00 $105.00 $105.00 02331 Resin 2 surf. - anterior $95.00 S131.00 $131.00 02332 Resin 3 surf. - anterior 5120.00 $162.00 S162.00 02335 Resin 4 surf. - anterior $141.00 5175.00 S175.00 02390 Resin based composite crown anterior S167.00 $275.00 $275.00 02391 Resin based composite I surface S80.00 $118.00 S118.00 02392 Resin based composite 2 surfaces S120.00 5158.00 S158.00 02393 Resin based composite 3 surfaces 5160.00 5196.00 $196.00 02394 Resin based composite 4 or more surfaces 5190.00 $237.00 $237.00 02920 Recement Crown 560.00 S75.00 $75.00 02930 SSC - primary S145.00 $185.00 5585.00 02931 SSC - permanent $174.00 $219.00 5219.00 02940 Sedative filling $59.00 S72.00 $72.00 02950 Crown build-up S100.00 $180.00 5180.00 02951 Pin placement $22.00 $45.00 S45.00 02970 Temporary crown 5139.00 S220.00 5220.00 03110 Pulp cap direct 535.00 $57.00 S57.00 03220 Pulpotomy Exc rest S103.00 $133.00 S133.00 03310 RCT - anterior 5369.00 S484.00 5484.00 03330 RCT - molar $405.00 $700.00 5700.00 03351 Recatcification - initial visit $174.00 $240.00 $240.00 03352 Recal: Interim medication replannt. $125.00 $180.00 $180.00 03353 Recalcification- final visit $200.00 $350.00 $350.00 04210 Gingivectomy/Gingivoplasty, $125.00 $420.00 $420.00 04211 Gingdomy/gingipisty 1-3 continous teeth $115.00 $155.00 $155.00 04240 Gingival flap proved. 4 or more p/quad $125.00 $490.00 $490.00 04241 Gingival flap proced 13 per quad $125.00 $420.00 $420.00 04341 Root planning/scale 4 or more $141.00 $174.00 $174.00 04342 Periodontal scaling 8 root planing 1-3 $110.00 $122.00 $122.00 04355 Gross scale - perio $103.00 $129.00 $129.00 04910 Periodontal maint. Treatment $77.00 $97.00 $97.00 05211 Maxillary partian denture $450.00 $450.00 07111... Coronet Remnants -Deciduous Teeth $80.00 $97.00 $97.00 07140 Ed. erupted tooth or exposed root $80.00 $109.00 $109.00 07210 Surgical ext. - erupted $136.00 $180.00 $180.00 07220 Soft tissue impact $97.00 $219.00 $219.00 07230 Partial bony impact $155.00 $281.00 $281.00 07240 Bony impact $250.00 $347.00 $347.00 07241 Bony impact w/complications $300.00 S404-00 $404.00 07250 Residual toots - unerupted $120.00 $218.00 $218.00 07270 Tooth Reimplantation $150.00 $386.00 $386.00 07510 1 & 0 intra oral $153.00 $158.00 $158.00 09110 Emergency palliative treatment $35.00 $50.00 $50.00 15