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Orange County Commissioner Approved Fee Schedule - FY 2013 -14 37 <br />Department/Program <br />Description <br />Current Fee <br />\` \ Last <br />Revision <br />Periodontal Maintenance <br />$81.00 <br />2009 <br />Amal One Surface Prim/ Perm <br />$90.00 <br />2012 <br />Amal Two Surface Prim/ Perm <br />$125.00 <br />2012 <br />Amal Three Surface Prim/Perm <br />$160.00 <br />2012 <br />Amal Four Surface Prim/Perm <br />$195.00 <br />2012 <br />Resin One Surface Anterior <br />$135.00 <br />2012 <br />Resin Two Surface Anterior <br />$160.00 <br />2012 <br />Resin Three Surface Anterior <br />$190.00 <br />2012 <br />Resin Four Surface Anterior <br />$215.00 <br />2012 <br />Resin Comp. Crown Ant. Prim <br />$185.00 <br />2009 <br />Resin Comp. 1sur.Post- Prim/Perm <br />$150.00 <br />2012 <br />Resin Comp. 2sur.Post- Prim/Perm <br />$190.00 <br />2012 <br />Resin Comp. 3sur.Posterior Perm <br />$215.00 <br />2012 <br />Resin Comp.4 +sur.Posterior Perm <br />$300.00 <br />2012 <br />Application of Desensitizing Medicament <br />$55.00 <br />2012 <br />and/or root surface per tooth <br />Pulpotomy <br />$52.00 <br />$137.00 <br />2009 <br />2012 <br />SSC Primary Tooth <br />$235.00 <br />2012 <br />SSC Permanent Tooth <br />$229.00 <br />2009 <br />Prebacricated Resin Crown <br />$235.00 <br />2009 <br />Prefab.est.coat SSC prim. Tooth <br />$214.00 <br />2009 <br />1__'M2012 <br />Sedative Filling <br />$80.00 <br />2012 <br />Palliative Treatment <br />$100.00 <br />2012 <br />Ext. Erupted Tooth Prim/Perm <br />$125.00 <br />Extraction Surgical - 100+ <br />$205.00 <br />2012 <br />Ext. corral remnants deciduous <br />$62.00 <br />2009 <br />Alveoplasty extractions p /quad. <br />$118.00 <br />2009 <br />Alveoplasty in conjunction with extraction 1 -3 <br />teeth per quadrant <br />$118.00 <br />2009 <br />Alveloplasty not in conjunction with extraction <br />4 or more tooth spaces per quadrant <br />$189.00 <br />2009 <br />Alveloplasty not in conjunction with extraction <br />1 -3 tooth spaces per quadrant <br />$162.00 <br />2009 <br />Recement Crown NOT cov. by MA <br />$57.00 <br />2009 <br />Study Models <br />$53.00 <br />2009 <br />I & D Minor Surgery <br />$186.00 <br />2009 <br />Occulsal Adjustment Limited <br />$86.00 <br />2009 <br />Fractured Tooth Txt. <br />$70.00 <br />21, 2009 <br />Pulp Cap- direct exp. Pulp MED <br />$75.00 <br />2012 <br />Pulp Cap- indirect nearly exposed <br />$75.00 <br />2012 <br />Biopsy Oral Tissue <br />$151.00 <br />1 2009 <br />Pin Retention/tooth <br />$67.00 <br />2012 <br />Band & Loop /Quadrant Impress <br />No Charge <br />Band & Loop /Quadrant Deliver 209/25 <br />$264.00 <br />2009 <br />Fixed Bilateral Impress <br />No Charge <br />Fixed Bilateral Deliver 419/30 <br />$482.00 <br />2009 <br />*Any fee changes wi I I be included in this column; <br />a bl ank besi de each f ee means there i s no f ee change i n FY 2013 -14 Comm i ssi oner Approved Fee Schedule <br />