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INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE Dental Services (Sliding Fee Scale does not apply CY 1243 CY 12-13 D0120 Periodic Oral Exam (Medicaid Return) 20. 00 D5110 Complete Denture - Max 450.00 D0140 Limited Oral Exam (EMER) 17.00 D5120 Complete Denture - Mand 450.00 D0150 Comprehensive Exam (Medicaid) 25. 00 55211 Upper Partial - Resin Base 400.00 D0210 Intra Oral Complete Sen (inc BW) 50. 00 D5212 Lower Partial - Resin Base $400. 0 D0220 PA Single-First 10.00 55213 Maxillary Partial Denture (Cast Metal) $550.0 D0230 PA-Each Additional 7.00 D5214 Mandibular Partial Denture (Cast Metal) $550. 0 D0270 Bitewings-Single L or R 10. 00 D5410 Adjust Complete Denture - Max $20.0 D0272 Bitewings-Two 18. 00 D5411 Adjust Complete Denture - Mand $20. 0 D0274 Bitewings-Four 25.00 D5421 Adjust Partial Denture - Max $20.0 D0330 Panoramic Film 45.00 D5422 Adjust Partial Denture - Mand $20. 0 D0470 Diagnostic Cast 20.00 D5510 Repair Complete Denture - Base + LAB $50 + lab D1110 Prophylaxis - Adult 14+ 40.00 D5520 Replace Teeth Complete Denture + LAB $50 + lab D1120 Prophylaxis - Child < 14 30.00 D5640 Replace Teeth - Partial Denture + LAB $50 + lab D1203 Topical Fluoride - Child < 14 14.00 D5650 Add Tooth to Existing Denture + LAB $50 + lab D1204 Topical Fluoride - Adult 14+ 15. 00 D5660 Add Clasp to Partial Denture + LAB $50 + lab D1206 Fluoride Varnish 15.00 D5730 Reline Complete Max - Chairside $90.0 D1330 Oral Hygiene Instruction 10 .00 D5731 Reline Complete Mand CChairside $90.0 D1351 Sealant - Per Tooth 3, 14% 19, 30 20.00 D5750 Reline Complete Max + LAB $50 + lab D1510 Space Main-Fixed-Unilat (includes lab fee) 150. 00 D5751 Reline Complete Mand + LAB $50 + lab D1515 Space Main-Fixed-Bilat (includes lab fee) 175.00 D5820 Interim Partial Denture (Upper Flipper) $ 100 + lab 51550 Recement Space Maint 20.00 D5821 Interim Partial Denture (Lower Flipper) $100 + lab D2140 AM 1 Surf - 45. 00 D7111 N Coron Remnants-Deciduous $40.0 D2150 AM 2 Surf - 55.00 D7140 Ext. Erupted Tooth or $40. 0 D2160 AM 3 Surf - 65.00 D7160 Sched Surg Post Op $40.0 D2161 AM 4 Surf - 75. 00 D7210 Surgical Erupted $70.0 D2330 Comp Resin-One Surface-Ant 45.00 D7220 Surg Ext-Soft Tissue Impact W$75,O D2331 Comp Two Surface Ant 55.00 D7230 Surg Ext-Part. Bony Impact D2332 Comp Three Surface Ant 65.00 D7240 Su Ext-Part. Bon Impact D2335 Corn Incisal Angle + 4 Surf 70.00 D7250 Root Recovery-Sur ery D2391 Comp Resin 1 Surf Post 55.00 D7280 Surg Exposure to Aid Eruption D2392 Comp Resin 2 Surf Post 65.00 D7285 Biopsy - Hard Tissue + LAB $100 + lab D2393 Comp Resin 3 Surf Post 75.00 D7286 Biopsy - Soft Tissue + LAB $85 + lab D2394 Comp Resin 4 > Surf Post 85.00 D7288 Brush Biopsy + LAB $40 + lab D2920 Recement Crown 20.00 D7310 Alveoloplasty w/Extraction $50.0 D2930 Stainless Steel - Primary 75 .00 D7320 Alveoloplasty No Extraction $75. 0 D2931 Stainless Steel Crown - Perm 100.00 1375101 & D - Intraoral (Drainage Abcess) $50.0 D2940 Sedative Filling 27.00 D9110 Palliative Services D2951 Pin Retention - Per Tooth 7.00 D9230 Analgesia (Nitrous) $35 .0 D2970 Temporary Crown 70.00 D9310 Consultation $20.0 D3110 Pulp Cap - Direct 20.00 D9630 Drugs $25. 0 D3120 Pulp Cap - Indirect 20.00 D9930 Treatment Complication (Post Surgery) $40.0 D3220 Vital Pulpotomy 60.00 D9940 Occlusal Guard I I $100 + lab D4341 Periodontal Scaling/Root Planning Quad # 50.00 D9951 Occlusal Adjustment - Limited 1 $50.0 D4342 Periodontal 1 -3 Teeth 50.00 D9972 External Bleaching (Upper & Lower Arch) $ 100.0 D4355 Full Mouth Debridement 65.00 Any other service provided not listed will be at Medicaid rate plus $15.00 United Way Succes By Six will be charged at 50% of the Dental Fees Page 7 of 9 c