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HomeMy WebLinkAboutC.054.93011_1587D2161 Amalgam 4 surf. - perm/primary $167.00 D2330 Resin 1 surf. - anterior $105.00 D2331 Resin 2 surf. - anterior $131.00 D2332 Resin 3 surf. - anterior $162.00 D2335 Resin 4 surf. - anterior $175.00 D2390 Resin based composite crown anterior $275.00 D2391 Resin based composite I surface $118.00 D2392 Resin based composite 2 surfaces $158.00 D2393 Resin based composite 3 surfaces $196.00 D2394 Resin based composite 4 or more surfaces $237.00 D2920* Receimirt Crown $75.00 D2930 SSC - primary $185.00 D2931 SSC - permanent $219.00 D2940 Sedative filling $72.00 D2950 Crown build-up $180.00 D2951 Pin placement $45.00 D2970 Temporary crown $220.00 D3110* Pulp cap direct $57.00 D3220 Pulpotomy Excl. rest $133.00 D3310 RCT - anterior $484.00 D3330 RCT - molar $700.00 D3351 Recalcification - initial visit $240.00 D3352 Recal: Interim medication replcmnt. $180.00 D3353 Recalcification - final visit $350.00 D4210 Gingivectomy/Gingivoplasty $420.00 D42I1 Gingitomy/gingiplsty 1-3 continous teeth $155.00 D4240 Gingival flap proced. 4 or more p/quad $490.00 D4241 Gingival flap proced 1-3 per quad $420.00 D4341 Root planning/scale 4 or more $174.00 D4342 Periodontal scaling & root planing 1-3 $122.00 D4355 Gross scale - perio $129.00 D4910 Periodontal maint. Treatment $97.00 D5211 Maxillary partian denture $450.00 D7111 Coronal Remnants -Deciduous Teeth $97.00 D7140 Ext. erupted tooth or exposed root $109.00 D7210 Surgical ext. - erupted $180.00 D7220 Soft tissue impact $219.00 D7230 Partial bony impact $281.00 D7240 Bony impact $347.00 D7241 Bony impact w/complications $404.00 D7250 Residual roots - unempted $218.00 D7270 Tooth Reimplantation $386.00 D7510 I & D intra oral $158.00 D9110 Emergency palliative treatment $50.00 D9230 Analgesia $49.00 D9610 Drug injection $75.00 D9630 Other drug/medication $40.00 * Medicaid does not cover effective 10/1/2004 SERVICE DESCRIPTION FEES FY 2007-2008 Medicaid & Sliding Scale services W8205 Parenting Education Classes*** $76.00 97802 Nutri. Therapy initial assessment (p/15 min.) $18.00 97803 Nutri Tberapy subseq. Assessmnt (p/15 min.) $18.00 S9442 Childbirth Education Classes $30.00 Services for Community Members/Organizations Basic Cholesterol Screen & Nutrition Education (per 30 min.) $35.00 Full Lipid Profile & Nutrition Eduation (per 30 min.) $30.00 Breast Pump Rental (per month) $20.00 Programs for Community Groups/Organizations Blood pressure/hypertension nutrition counseling (per 30 min.) $15.00 Community First Aid and CPR course $45.00 Community First Aid and CPR (Adult, Infant & Child CPR) $45.00 Professional Rescuer CPR (Adult, Infant & Child CPR and AED) Does not include First Aid $52.00 Grocery Store Tour -Health Foods (per person) $10.00 Information boots at fairs or health fairs Donation $0.00 and up Health Topic Seminars (for City, State/County gvmmnt, civic groups, schools, churches and/or non-profits)Donation $0.00 and up Health Topic Seminars (Business & Industries - per person)** $5.00 to $100.0 Individual weight loss counseling (per 30 min.) $15.00 Weight loss counseling (package of five 30 min sessions) $60.00 Stress Management Class* $40.00