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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE --Effective Nov.01, 2006 <br /> Dental Services(Sliding Fee Scale does not apply) <br /> D0120 Periodic Oral Exam $15.00 D5130 Immediate Denture- Max $310.00 <br /> D0140 Emergency Examination $15.00 D5140 Immediate Denture- Man $310.00 <br /> D0150 Oral Examination $16.00 D5211 Acrylic Partial (Upper) $285.00 <br /> D0210 Intra Oral Complete Sen (inc BW) $32.00 D5212 Acrylic Partial (Lower) $285.00 <br /> D0220 Periapical First Film $4.00 D5213 Cast Metal Partial (Upper) $425.00 <br /> D0230 Periapical Addt'l Film $3.00 D5214Cast Metal Partial (Lower) $425.00 <br /> D0240 Intra Oral-Occlusal $8.00 D5255 Maxillary flex partiall $560.00 <br /> D0270 Bitewing-Single Film $6.00 D5256 Mandibular flex partial $560.00 <br /> D 0272 Bitewing-Two Films $9.00 D5281 Partial Denture $249.25 <br /> D0274 Bitewing- Four Films $11.00 D5410 Adj Denture Max $14.00 <br /> D0330 Panoramic film $30.00 D5411 Adj Denture Man $14.00 <br /> D0350 Oral/Facial photo image $7.00 D5421 Adj Partial Denture Max $14.00 <br /> DD0470 Diagnostic Casts $22.00 D5422 Adj Partial Denture Man $14.00 <br /> D1110 Prophylaxis-Adult $36.00 D5510 Repair Complete Denture Base+ LAB $45.00 <br /> D1120 Prophylaxis-Child $14.00 D5520 Replace Teeth Complete Denture+ LAB $75.00 <br /> D12037opical Fluoride-Child $11.00 D5640 Replace Teeth Partial Denture+ LAB $30.00 <br /> D1204 Topical Fluoride-Adult $16.00 D5650 Add Tooth Partial Existing Denture+ LAB $30.00 <br /> D1330 Oral Hygiene Instructions $6.00 D5660 Add Clasp Partial Denture+ LAB $45.00 <br /> D1351 Sealant-Per Tooth $13.00 D5710 Rebase Maxillary denture $201.25 <br /> D1510 Space Maintainer- Fixed Unilateral $72.00 D5711 Rebase Mandibular denture $201.25 <br /> D1515 Space Maintainer- Fixed Bilateral $117.00 D5730 Reline Complete Max-Chair side $63.00 <br /> D1550 Recement Space Maintainer $17.00 D5731 Reline Complete Man-Chair side $63.00 <br /> D2140 Amalgam -One Surface D or P $31.00 D5750 Reline Complete Max+ LAB $100.00 <br /> D2150 Amalgam -Two Surface D or P $41.00 D5751 Reline Complete Man + LAB $100.00 <br /> D2160 Amalgam-Three Surface D or P $51.00 D5820 Acrylic Flipper- Upper $175.00 <br /> D2161 Amalgam-Four or more D or P $61.00 D5821 Acrylic Flipper-Lower $175.00 <br /> D2330 Resin-One Surface Anterior Primary $34.00 D5899 Unspec removable prosthodontic+ LAB $425.00 <br /> D2331 Resin-Two Surface Anterior Primary $39.00 D7111 Single Tooth Extraction(Child) $27.00 <br /> D2332 Resin-Three Surface Anterior Primary $44.00 D7140 Single Tooth Extraction(Adult) $35.00 <br /> D2335 Resin-Four or more Anterior Primary $72.00 D7210 Surgical Removal of Tooth $75.00 <br /> D2390 Anterior Composite Resin Crown $72.00 D7220 Removal of Impacted Tooth (Soft Tissue) $62.00 <br /> D2391 Resin-One Surface Post Primary $31.00 D7230 Removal of Impacted Tooth (Partially Bony) $85.00 <br /> D2392 Resin-Two Surface Post Primary $41.00 D7240 Removal of Impacted Tooth (Completely Bony) $79.00 <br /> D2393 Resin-Three Surface Post Primary $51.00 D7241 Removal of Impacted Tooth (Completely Bony unusual) $82.00 <br /> D2394 Resin- Four or more $84.75 D7250 Root Recovery-Surgical 1 $65.00 <br /> D2740 Crown/Porcelain/Ceramic Substrate $396.00 D7270 Tooth Reimplant/Stabilization Child Only $27.00 <br /> D2752 Permanent Crown $246.00 D7281 Surgical Exposure to Aid Eruption $45.00 <br /> D2792 Gold Crown (Posterior)+ LAB $150.00 D7285 Biopsy- Hard Tissue $118.75 <br /> D2799 Provisional single crown $75.00 D7286 Biopsy-Soft Tissuel $81.25 <br /> D2920 Recement Crown $17.00 D7310 Alveoplasty With Extraction $45.00 <br /> D2930 Prefabricated Steel Crown Primary $68.00 D7320 Alveoplasty No Extract 1-quadrant) $85.00 <br /> 10/23/2006CLFEE2006-07 Page 6 of 11 <br />