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2018-066
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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br />FEE SCHEDULE - <br />D0120 Periodic Oral Exam (Medicaid Return) <br />DO140 Umked Oral Exam (EMER) <br />D0150 Comprehensive Exam (Medicaid) <br />CY 18-19 Fee NO CHANGE <br />Dental Services (Sliding Fee Scale does not apply) <br />22.50 D5110 Complete Denture - Max _ <br />12.00 D5120 Complete Denture - Mand <br />24.00 05211 Upper Partial - Resin Base <br />CY 18-19 Fee <br />461.00 <br />461.00 <br />400.00 <br />D0210 Intra Oral Complete Sen (inc BW) <br />48.00 <br />D5212 Lower Partial - Resin Base <br />$400. <br />D0220 PA Single -First <br />6.00 <br />D5213 Maxillary Partial Denture (Cast Metal) <br />$S50.04 <br />D0230 PA -Each Additional <br />4S0 <br />DS214 Mandibular Partial Denture (Cast Metal) <br />$550. <br />D0270 Bitewings -Single L or R <br />9.00 <br />D5410 Adjust Complete Denture - Max <br />$21. <br />D0272 Bkewings-Two <br />13.50 <br />D5411 Adjust Complete Denture - Mand <br />$21. <br />D0274 Bkewings-Four <br />1650 <br />05421 Adjust Partial Denture - Max <br />$21. <br />D0330 Panoramic Film <br />45.00 <br />D5422 Adjust Partial Denture - Mand <br />$21. <br />D0470 Diagnostic Cast <br />33.00 <br />05510 Repair Complete Denture - Base + LAB <br />$65.50+ lob <br />D1110 Prophylaxis - Adult 14+ <br />27.00 <br />D5S20 Replace Teeth Complete Denture + LAB <br />$S8 + lab <br />D1120 Prophylaxis - Child <14 <br />21.00 <br />DS640 Replace Teeth - Partial Denture + LAB <br />$S8 + lab <br />D1203 Topical Fluoride - Child <14 <br />11.00 <br />D56S0 Add Tooth to Existing Denture + LAB <br />$62.50 + lab <br />D1204 Topical Fluoride - Aduk 14+ <br />11.00 <br />D5660 Add gasp to Partial Denture + LAB <br />$77.50 + lab <br />D1206 Fluoride Varnish <br />17.00 <br />D5730 Reline Complete Max - Chairside <br />$94.00 <br />D1208 Topcal application of fluoride <br />17.00 <br />01330 Oral Hygiene Instruction <br />9.00 <br />DS731 Reline Complete Mand - Chairside <br />$94.00 <br />D33S1 Sealant - Per Tooth 3, 14, 19, 30 <br />1950 <br />DS7S0 Reline Complete Max + LAB <br />$168 + lab <br />D1510 Space Main-Fha!d-Unilat (includes lab fee) <br />150.00 <br />D57S1 Reline Complete Mand + LAB <br />$168 + lab <br />D1515 Space Main-Fixed-Bilat (includes lab fee) <br />175.00 <br />DS820 Interim Partial Denture (Upper Flipper) <br />$163.50 + lab <br />D15S0 Recement Space Maint <br />25.00 <br />DS821 Interim Partial Denture (Lower Flipper) <br />$163.50+lob <br />02140 AM 1 Surf - <br />46.50 <br />D7211 N Coron Remnants -Deciduous <br />$40. <br />DZ150 AM 2 Surf - <br />61.00 <br />D7140 Ext. Erupted Tooth or <br />$40 <br />02160 AM 3 Surf - <br />76.00 <br />D7160 Schad Surg Post Op <br />$40. <br />D2161 AM 4 Surf - <br />91.00 <br />D7210 Surgical Erupted <br />$70.0101 <br />D2330 Comp Resin -One Surface -Ant <br />51.00 <br />D7220 Surg Ext -Soft Tissue Impact <br />$92. <br />DZ331 Comp Two Surface Ant <br />58.00 <br />D7230 Surg Ext -Part. Bony Impact <br />$114. <br />02332 Comp Three Surface Ant <br />6SS0 <br />D7240 Surg Ext -Part. Bony Impact <br />$114. <br />DZ390 Resin based composke,crown anterior <br />107.50 <br />D233S Corn Incisal Angle + 4 Surf <br />10750 <br />D7250 Root Recovery -Surgery <br />$90. <br />D2391 Comp Resin 1 Surf Post <br />55.00 <br />D7280 Surg Exposure to Aid Eruption <br />$202. <br />D2392 Comp Resin 2 Surf Post <br />65.00 <br />D7285 Biopsy - Hard Tissue + LAB <br />$100 + lab <br />D2393 Comp Resin 3 Surf Post <br />76.00 <br />D7286 Biopsy - Soft Tissue + LAB <br />$85 + lab <br />D2394 Comp Resin 4 > Surf Post <br />85.00 <br />D7288 Brush Biopsy + LAB 1$40 <br />+ lab <br />DZ920 Recement Crown <br />25.50 <br />D7310 Alveoloplasty w/Extraction <br />$70.04 <br />D2930 Stainless Steel - Primary <br />101.50 <br />D7320 Alveoloplasty No Extraction <br />$83 <br />DZ931 Stainless Steel Crown - Perm <br />101.50 <br />D7S10 I & D - Intreoral (Drainage Abcess) <br />$70.04 <br />D2940 Sedative Filling <br />27.00 <br />09110 Palliative Services 1 <br />$20.001 <br />D2951 Pin Retention - Per Tooth <br />7.00 <br />D9230 Analgesia (Nitrous) <br />$41. <br />D2970 Temporary Crown <br />70.00 <br />09310 Consukation <br />$Z0.001 <br />D3110 Pulp Cap - Direct <br />20.00 <br />D9630 Drugs <br />$25. <br />D3120 Pulp Cap - Indirect <br />20.00 <br />D9930 Treatment Complication (Post Surgery) <br />$40. <br />D3220 Vital Pulpotomy <br />75.00 <br />D9940 Occlusal Guard 1 <br />$100+lob <br />D3310 Endodontic therapy anterior w/o final restoration <br />220.00 <br />D9951 Occlusal Adjustment - Umked <br />$50. <br />D3320 Endodontic therapy bicuspid w/o final restoration <br />282.50 <br />D9972 External Bleaching (Upper & Lower Arch) <br />$100. <br />D3330 Endodontic therapy molar w/o final restoration <br />349.50 <br />D4341 Periodontal Scaling/Root Planning Quad N <br />50.00 <br />04342 Periodontal 1-3 Teeth 50.00 <br />D43S5 Full Mouth Debridement 7750 <br />rry other service provided not listed will be at Medicaid rate plus $15.00 <br />Pape 6 of 7 7M 1/2018 <br />
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