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INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 Dental Services(Sliding Fee Scale does not apply)CONTINUED D2951 Pin Retention-Per Tooth $2.00 D7510 1&D-Intraoral (Dranage Abcess) $47.00 D2954 Prefab Post/Core in Add Crown $53.00 D7960 Frenulectomy $106.75 D2970 Temp Crown $42.00 D9110 Palliative Services $13.00 D3110 Pulp Cap Direct $13.00 D9230 Analgesia(Nitrous) $28.00 D3120 Pulp Cap Indirect $11.00 D9310 Consultation $18.00 D3220 Therapeutic Pulpotomy $50.00 D9630 Drugsj $19.25 D3310 Root Canal(Anterior) $148.00 D9920 Behavior Management $24.00 D3320 Root Canal(Bicuspid) $190.00 D9930 Unsched Post Op-Surgery $33.75 D3330 Root Canal(Molar) $235.00 D9940 Occlusal Guard-Hard $153.00 D4240 Periodontal Surgery $184.00 D9941 Occlusal Guard-Soft $125.00 D4341 Root Planning per Quadrant $40.00 D9951 Occlusal Adjustment-Limited $49.00 D4355 Full Mouth Debridement $46.25 D9972 External Bleaching 1 $139.30 D5110 Upper Denture(Full) $325.00 Resin Elected-One Surface** $55.00 D5120 Lower Denture(Full) $325.00 Resin Elected-Two Surface** $65.00 D5130 Immediate Denture-Max $418.00 Resin Elected-Three Surface** $80.00 D5140 Immediate Denture-Man $412.50 Resin Elected-Four or more** $105.00 **If client requests Resin fillings. Laboratory Services 0%-A 17%-B 33%-C 50%-D 67% -E 83%- F 100%-G COST IN-HOUSE LAB LAB $0.00 $1.70 $3.30 $5.00 $6.70 $8.30 $10.00 $10.00 Contracted Laboratory Services LAB $0.00 $3.40 $6.60 $10.00 $13.40 $16.60 $20.00 $20.00 NOTE: Tests which exceed a charge of$100.00 will be billed individually on sliding fee scale percentage based on IRCHD cost of lab service. IN-HOUSE and CONTRACTED LAB Fee is for all labs performed at the time of service. Pharmacy 4 Pharmaceutical items will be billed on a per pill basis at IRCHD cost. Attached to this fee schedule is a current listing of prices. An itemized pharmaceutical listing is updated weekly and is available by contacting the cashier. Items received from the State Pharmacy as in-kind donation at no cost to IRCHD will not'be charged to the patient. Medical Records Fees Copy of Medical Record/per page $1.00 per page for the first 25 pages; $.25 each additional page thereafter. NOTE: Florida Statutes regarding release of medical records must be met prior to release of medical records to any source. No fees are charged to physician offices/other medical agents with the understanding that IRCHD will also be exempt from such payment. 9/12/2005CLFEE2005-06 Page 5 of 8