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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHE` F <br /> Dental Services(Sliding Fee Scale does notapply) CY 12-13 CY 12-13 <br /> D0120 Periodic Oral Exam(Medicaid Return) 20.00 D5110 Complete Denture-Max 450.00- <br /> D0140 Limited Oral Exam(EMER) 17.00 D5120 Complete Denture-Mand 450.00 <br /> D0150 Comprehensive Exam Medicaid 25.00 D5211 Upper Partial-Resin Base 400.00 <br /> D0210 Intra Oral Complete Sen(inc BW) 50.00 D5212 Lower Partial-Resin Base $400.0 <br /> D0220 PA Single-First 10.00 D5213 Maxillary Partial Denture Cast Metal) $550.0 <br /> D0230 PA-Each Additional 7.00 D5214 Mandibular Partial Denture Cast Metal) $550.0 <br /> D0270 Bitewings-Single L or R 10.00 D5410 Adjust Complete Denture-Max $20.0 <br /> D0272 Bitewings-Two 18.00 D5411 Adjust Complete Denture-Mand $20.0 <br /> D0274 Bitewings-Four 25.00 D5421 Adjust Partial Denture-Max $20.0 <br /> D0330 Panoramic Film 45.00 D5422 Adjust Partial Denture-Mand $20.0 <br /> D0470 Diagnostic Cast 20.00 D5510 Repair Complete Denture-Base+LAB $50+lab <br /> D1110 Prophylaxis-Adult 14+ 40.00 D5520 Replace Teeth Complete Denture+LAB $50+lab <br /> D1120 Prophylaxis-Child<14 30.00 D5640 Replace Teeth-Partial Denture+IAB $50+lab <br /> D1203 Topical Fluoride-Child<14 14.00 D5650 Add Tooth to Existing Denture+LAB $50+lab <br /> D1204 Topical Fluoride-Adult 14+ 15.00 D5660 Add Clasp to Partial'Denture+IAB $50+lab <br /> D1206 Fluoride Varnish 15.00 D5730 Reline Complete Max-Chairside _ $90.0 <br /> D1330 Oral Hygiene Instruction 10.00 D5731 Reline Complete Mand-Chairside $90.0 <br /> D1351 Sealant-Per Tooth 3, 14, 19, 30 20.00 D5750 Reline Complete Max+LAB $50+lab <br /> D1510 Space Main-Fixed-Unilat includes lab fee) 150.00 D5751 Reline Complete Mand+LAB $50+lab <br /> D1515 Space Main-Fixed-Bilat includes lab fee 175.00 D5820 Interim Partial Denture(Upper Flipper) $100+lab <br /> D1550 Recement Space Maint 20.00 D5821 Interim Partial Denture Lower Flipper) $100+lab <br /> D2140 AM 1 Surf- 45.00 D7111 N Coron Remnants-Deciduous $40.0 <br /> D2150 AM 2 Surf- 55.00 D7140 Ext. Erupted Tooth or $40.0 <br /> D2160 AM 3 Surf- 65.00 D7160 Sched Surg Post Op $40.0 <br /> D2161 AM 4 Surf- 75.00 D7210 Surgical Erupted 1 $70.0 <br /> D2330 Comp Resin-One Surface-Ant 45.00 D7220 Surg Ext-Soft Tissue Impact $75.0 <br /> D2331 Comp Two Surface Ant 55.00 D7230 Surg Ext-Part. Bony Impact $80.0 <br /> D2332 Comp Three Surface Ant 65.00 D7240 Surg Ext-Part. Bony Impact $100.0 <br /> D2335 Corn Incisal Angle+4 Surf 70.00 D7250 Root Recovery-Surgery $90.0 <br /> D2391 Comp Resin 1 Surf Post 55.00 D7280 Sugg Exposure to Aid Eruption $75.0 <br /> D2392 Comp Resin 2 Surf Post 65.00 D7285 Biopsy-Hard Tissue+LAB $100+lab <br /> D2393 Comp Resin 3 Surf Post 75.00 D7286 Biopsy-Soft Tissue+LAB $85+lab <br /> D2394 Comp Resin 4>Surf Post 85.00 D7288 Brush Biopsy+LAB $40+lab <br /> D2920 Recement Crown 20.00 D7310 Aiveolo tasty w/Extraction $50.0 <br /> D2930 Stainless Steel-Primary 75.00 D7320 Alveoloplasty No Extraction $75.00- <br /> D2931 Stainless Steel Crown-Perm 100.00 D7510 I&D-Intraoral(Drainage Abcess) $50.0 <br /> D2940 Sedative Filling 27.00 D9110 Palliative Services $20.0 <br /> D2951 Pin Retention-Per Tooth 7.00 D9230 Analgesia Nitrous $35.0 <br /> D2970 Temporary Crown 70.00 D9310 Consultation $20.0 <br /> D3110 Pulp Cap-Direct 20.00 D9630 Drugs $25.0 <br /> D3120 Pulp Cap-Indirect 20.00 D9930 Treatment Complication(Post Surgery) $40.0 <br /> D3220 Vital Pulpotomy 60.00 D9940 Occlusal Guard $100+lab <br /> D4341 Periodontal Scaling/Root Plannin Quad# 50.00 D9951 Occlusal Adjustment-Limited $50.0 <br /> D4342 Periodontal 1-3 Teeth 50.00 D9972 External Bleaching Up er&Lower Arch $100.0 <br /> D4355 Full Mouth Debridement 65.00 <br /> 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 <br /> Page 7 of 9 <br />