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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE -- Effective Oct 1 , 2004 <br /> Dental Services (Sliding Fee Scale does not apply) CONTINUED _ <br /> D2335 Resin - Four or more Anterior Primary $72 . 00 D7240 Removal of Impacted Tooth (Completely Bony) $79 .00 <br /> D2390 Anterior Composite Resin Crown $72 .00 D7241 Removal of Impacted Tooth (Completely Bony unusual ) $82 .00 <br /> D2391 Resin - One Surface Post Primary $31 .00 D7250 Root Recovery - Sergical _ $54 . 00 <br /> D2392 Resin - Two Surface Post Primary $41 .00 D7270 Tooth Reimplant/Stabilization _ $27.00 <br /> D2393 Resin - Three Surface Post Primary $51 .00 D7281 Surgical Exposure to Aid Eruption $38 . 00 <br /> D2394 Resin - Four or more $78 .00 D7285 Biopsy - Hard Tissue $ 110 .00 <br /> D2752 Permanent Crown $231 .25 D7286 Biopsy - Soft Tissue $77 . 00 <br /> D2792 Gold Crown (Posterior) $228 .25 D7310 Alveolectomy With Extraction $45.00 <br /> D2920 Recement Crown $ 17 .00 D7320 Alveolectomy No Extraction $56 .00 <br /> D2930 Prefabricated Steel Crown Primary $68 . 00 D7410 Surgical Excision< 1 .25cm $ 110 . 75 <br /> D2931 Prefabricated Steel Crown Permanent $68.00 D7411 Surgical Excision> 1 .25cm $ 167.25 <br /> D2940 Sedative Filling _ $1 18 . 00 D7450 Cyst Removal $ 125 .25 <br /> D2950 Crown Build-Up I $65.00 . _� D7471 Removal of Exotosis t $ 170 .25 <br /> D2951 Pin Retention - Per Tooth } 1 $2 . 00 D7510 18-D - Intraoral (Dranage Abcess) $47 . 00 <br /> D2954 Prefab Post/Core in Add Crown $53.00 D7960 Frenulectomy $ 106. 75 <br /> D2970 Temp Crown $42 .00 D9110 Palliative Services $ 13 .00 <br /> D3110 Pulp Cap Direct $ 13. 00 D9230 Analgesia (Nitrous) $28 .00 <br /> D3120 Pulp Cap Indirect $ 11 .00 D9310 Consultation $ 18.00 <br /> D3220 Therapeutic Pulpotomy - $50 . 00 D9630 Drugs $ 18 .25 <br /> D3310 Root Canal (Anterior) $ 148.00 D9920 Behavior Management $24,00 <br /> D3320 Root Canal (Bicuspid ) $ 190 . 00 D9930 Unsched Post Op - Surgery $33 . 75 <br /> D3330 Root Canal (Molar) $235.00 D9940 Occlusal Guard - Hard $ 153.00 <br /> D4240 Periodontal Surgery $ 184 .00 D9941 Occlusal Guard - Soft $ 125.00 <br /> D4341 Root Planning per Quadrant T $40.00 D9951 Occlusal Adjustment - Limited $49.00 <br /> D4355 Full Mouth Debridement $46.25 D9972 External Bleaching $ 139. 30 <br /> D5110 Upper Denture (Full) $310.00 Resin Elected - One Surface" $50. 75 <br /> D5120 Lower Denture (Full ) $310.00 1 Resin Elected - Two Surface" $64.05 <br /> D5130 Immediate Denture - Max $418.00 Resin Elected - Three Surface" $78. 75 <br /> D5140 Immediate Denture - Man $412 .50 Resin Elected - Four or more"* $ 100 .45 <br /> "If client requests Resin fillings . <br /> 11 /2/2004CLFEE2004-05 Page 4 of 7 <br />