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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE --Effective Oct 1,2005 <br /> Dental Services(Sliding Fee Scale does not apply) , <br /> D0120 Periodic OralExam $15.00 15211 Acrylic Partial(Upper) $285.00 <br /> D0140 Emergency Examination $15.00 D5212 Acrylic Partial (Lower) $285.00 <br /> D0150 Oral Examination $16.00 D5213 Cast Metal Partial(Upper) $425.00 <br /> D0210 Intra Oral Complete Sen (inc BW) $32.00 D5214Cast Metal Partial(Lower) $425.00 <br /> D0220 Periapical First Film $4.00 D5281 Partial Denture $243.75 <br /> D0230.Pedapical Addfl Film $3.00 D5410 Adj Denture Max $14.00 <br /> D0240 Intra Oral-Occlusal $8.00 D5411 Adj Denture Man $14.00 <br /> D0270 Bitewing-Single Film $6.00 D5421 Adj Partial Denture Max $14.00 <br /> D 0272 Bitewing-Two Films $9.00 D5422 Adj Partial Denture Man $14.00 <br /> 10274 Bitewing-Four Films $11.00 D5510 Repair Complete Denture Base $90.00 <br /> DD0470 Diagnostic Casts $22.00 D5520 Replace Teeth Complete Denture $90.00 <br /> D1110 Prophylaxis`Adult $34.00 D5640 Replace Teeth Partial Denture $90.00 <br /> D1120 Prophylaxis-Child $14.00 D5650 Add Tooth Partial Existing Denture $100.00 <br /> D1203 Topical Fluoride-Child $11.00 D5660 Add Clasp Partial Denture $150.00 <br /> D1204 Topical Fluoride Adult $16.00 D5730 Reline Complete Max-Chairside $63.00 <br /> D1330 Oral Hygiene Instructions $6.00 D5731 Reline Complete Man-Chairside $63.00 <br /> D1351 Sealant-Per Tooth $13.00 - D5750 Reline Complete Max-Lab $180.00 <br /> D1510 Space Maintainer-Fixed Unilateral $72.00 D5751 Reline Complete Man-Lab $180.00 <br /> D1515 Space Maintainer-Fixed Bilateral $117.00 D5820 Acrylic Flipper-Upper $150.00 <br /> D1550 Recement Space Mait $17.00 D5820 Acrylic Flipper-Lower $150.00 <br /> D2140 Amalgam-One Surface D or P $31.00 D6242 Pontic Porcelain Fused to Gold $232.25 <br /> D2150 Amalgam-Two Surface D or P $41.00 16752 Crown Porcelain Fused to Gold $237.50 <br /> D2160 Amalgam-Three Surface D or P $51.00 D7111 Single Tooth Extraction (Child) $27.00 <br /> D2161 Amalgam-Four or more D or P $61.00 D7140 Single Tooth Extraction (Adult) $35.00 <br /> D2330 Resin-One Surface Anterior Primary $34.00 D7210 Surgical Removal of Tooth $55.00 <br /> D2331 Resin-Two Surface Anterior Primary $39.00 D7220 Removal of Impacted Tooth(Soft Tissue) $62.00 <br /> D2332 Resin-Three Surface Anterior Primary $44.00 D7230 Removal of Impacted Tooth(Partially Bony) $77.00 <br /> D2335 Resin-Four or more Anterior Primary $72.00 D7240 Removal of Impacted Tooth(Completely Bony) $79.00 <br /> D2390 Anterior Composite Resin Crown $72.00 D7241 Removal of Impacted Tooth (Completely Bony unusual) $82.00 <br /> D2391 Resin-One Surface Post Primary $31.00 D7250 Root Recovery-Sergical $54.00 <br /> D2392 Resin-Two Surface Post Primary $41.00 D7270 Tooth.Reimplant/Stabilization $27.00 <br /> D2393 Resin-Three Surface Post Primary. $51.00 D7281 Surgical Exposure to Aid Eruption $38.00 <br /> D2394 Resin-Four or more $78.00 D7285 Biopsy-Hard Tissue $110.00 <br /> D2752 Permanent Crown $231.25 D7286 Biopsy-Soft Tissuel $77.00 <br /> D2792 Gold Crown (Posterior) $228.25 17310 Alveolectomy With Extraction $45.00 <br /> D2920 Recement Crown $17.00 D7320 Alveolectomy No Extraction $56.00 <br /> 12930 Prefabricated Steel Crown Primary $68.00 D7410 Surgical Excision<1.25cm $110.75 <br /> D2931 Prefabricated Steel Crown Permanent $68.00 D7411 Surgical Excision>1.25cm $167.25 <br /> D2940 Sedative Filling $18.00 D7450 Cyst Removal 1 $125.25 <br /> D2950 Crown Build-Up $65.00 D7471 Removal of Exotosis $170.25 <br /> 9/12/2005CLFEE2005-06 Page 4 of 8 <br /> i <br />