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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE -- Effective Oct 1 , 2004 <br /> Travel Immunizations (Sliding Fee Scale does not apply -- Per Injection) <br /> Travel Immunization Consult Visit $32 .00 <br /> Hepatitis B Vaccine $35 .00 <br /> Hepatitis A Vaccine $25 .00 <br /> Hepatitis A Vaccine - Children $25.00 <br /> Twinrix (Hep A & B) $50 . 00 <br /> Hep A Immune Globulin* $30.00 Per 2 ml dose - <br /> Meningococcal $75. 00 <br /> Tetanus _F__-$ 15.00 <br /> Typhoid $65 .00 <br /> Yellow Fever _ $90.00 <br /> *As available <br /> Dental Services (Sliding Fee Scale does not apply) <br /> D0120 Periodic OralExam $ 15.00 D5211 Acrylic Partial ( Upper) _ $ 165.00 <br /> D0140 Emergency Examination $8 . 00 1D5212 Acrylic Partial (Lower) $ 165 . 00 <br /> D0150 Oral Examination $ 16.00 D5213 Cast Metal Partial ( Upper) $315.00 <br /> D0210 Intra Oral Complete Sen (inc BW ) $32 .00 D5214Cast Metal Partial (Lower) $315.00 <br /> D0220 Periapical First Film $4.00 D5281 Partial Denture $243. 75 <br /> D0230 Periapical Addt'l Film $3 . 00 D5410 Adj Denture Max $ 14.00 <br /> D0240 Intra Oral - Occlusal _ $8.00 D5411 Adj Denture Man $ 14.00 <br /> D0270 Bitewing - Single Film $6 . 00 D5412 Adj Partial Denture Max $ 14.00 <br /> D 0272 Bitewing - Two Films $9.00 D5413 Adj Partial Denture Man $ 14 ,00 <br /> D0274 Bitewing - Four Films $ 11 .00 D5510 Repair Complete Denture Base $44.00 <br /> 000470 Diagnostic Casts $22.00 1 D5520 Replace Teeth Complete Denture $39.00 <br /> D1110 Prophylaxis - Adult $34.00 D5640 Replace Teeth Partial Denture _ $39.00 <br /> $ 14 . 00 D5650 Add Tooth Partial Existing Denture T <br /> 01120 Prophylaxis - Child $42 .00 <br /> D1203 Topical Fluoride - Child $ 11 .00 D5660 Add Clasp Partial Denture $52 .00 <br /> D1204 Topical Fluoride - Adult $ 16 .00 D5730 Reline Complete Max - Chairside $63.00 <br /> D1330 Oral Hygiene Instructions $6 .00 D5731 Reline Complete Man - Chairside $63.00 <br /> 01351 Sealant - Per Tooth $ 13.00 D5750 Reline Complete Max - Lab $ 113.00 <br /> D1510 Space Maintainer - Fixed Unilateral $72 .00 D5751 Reline Complete Man - Lab $ 113.00 <br /> D1515 Space Maintainer - Fixed Bilateral $ 117.00 D5820 Acrylic Flipper - Upper $ 110 . 00 <br /> D1550 Recement Space Mait $ 17 .00 D5820 Acrylic Flipper - Lower - $ 110 ,00 <br /> D2140 Amalgam - One Surface D or P $31 .00 D6242 Pontic Porcelain Fused to Gold $232 .25 <br /> D2150 Amalgam - Two Surface D or P $41 .00 D6752 Crown Porcelain Fused to Gold $237.50 <br /> D2160 Amalgam - Three Surface D or P $51 .00 D7111 Single Tooth Extraction (Child ) $27 .00 <br /> D2161 Amalgam - Four or more D or P $61 .00 D7140 Single Tooth Extraction (Adult) $27.00 <br /> D2330 Resin - One Surface Anterior Primary $34 .00 D7210 Surgical Removal of Tooth $40 .00 <br /> D2331 Resin - Two Surface Anterior Primary $39.00 D7220 Removal of Impacted Tooth (Soft Tissue) $62 .00 <br /> D2332 Resin - Three Surface Anterior Primary $44 .00 D7230 Removal of Impacted Tooth Partial) Bon $77 .00 <br /> 11 /2/2004CLFEE2004-05 Page 3 of 7 <br />