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M anager's Recommended Fee Schedule- FY 2015-16 37 <br /> Manager's Recommended Fee Last <br /> Department/Program Description Current Fee Schedule for FY 2015-16* Revision <br /> ADA Code <br /> Dental Health E0150 Comprehensive Oral Evaluation $80.00 2013 <br /> Oral Evaluation for a patient under three years of <br /> age and counse with primary caregiver 2 $55.00 $61.00 2013 <br /> D0120 Periodic Oral Evaluation $45.00 2013 <br /> D0140 Limited Oral Evaluation $69.00 2013 <br /> D0170 Re-evaluation-limited,problem $65.00 2013 <br /> D9310 Consultation $122.00 2013 <br /> D0330 Panoramic Film $100.00 2013 <br /> D0270 BWX 1 Film $26.00 2013 <br /> D0272 BWX 2 Films $41.00 2013 <br /> D0273 Bite s-thre Slurs $51.00 2013 <br /> D0274 BWX4 Films $58.00 2013 <br /> D0220 1st Immoral PA Film $26.00 2013 <br /> D0230 Additional PA Film $23.00 2013 <br /> D0240 Immoral Occulusal Film $38.00 2013 <br /> D0210 Full Mouth Series w BWX $120.00 2013 <br /> D1120 Pro h/Child under age 13 $61.00 2013 <br /> E1110 Pro h/Adulta e 13 and up $82.00 2013 <br /> D1203 Fluoride Varnish(age 13&under $33.00 2013 <br /> D1204 Fluoride Varnish(age 13-20 $33.00 2013 <br /> Topical Fluoride varnisktherapeutic application for <br /> D 1206 moderate to high caries risk patients $39.00 2013 <br /> D1351 Sealant/NEWLY ERUPTED TEETH $49.00 2013 <br /> _Re-applic ation of sealant 2 N/A $49.00 New <br /> D4342 Scale/Root Planing 1-3 teeth / $167.00 2013 <br /> D4341 Scale Root Planing 4>teeth / $231.00 2013 <br /> D4355 Full mouth Debridement $168.00 2013 <br /> D4910 Periodontal Maintenance $127.00 2013 <br /> D2140 Amal One Surface Prim/Perm $130.00 2013 <br /> D2150 Amal Two Surface Prim/Perm $164.00 2013 <br /> D2160 Amal Three Surface Prim/Perm $198.00 2013 <br /> D2161 Amal Four Surface Prim/Perm $236.00 2013 <br /> D2330 Resin One Surface Anterior $148.00 2013 <br /> D2331 Resin Two Surface Anterior $183.00 2013 <br /> D2332 Resin Three Surface Anterior $227.00 2013 <br /> D2335 Resin Four Surface Anterior $288.00 2013 <br /> D2390 Resin Comp.Crown Ant.Prim $414.00 2013 <br /> D2391 Resin Comp.1sur.Post-Prim/Perm $162.00 2013 <br /> D2392 Resin Comp.2sur.Post-Prim/Perm $212.00 2013 <br /> D2393 Resin Comp.3sur.Posterior Perm $261.00 2013 <br /> D2394 Resin Com.4+sur.Posterior Perm $314.00 2013 <br /> D9910 Applicati on ofDesensitizingMedicament $57.00 2013 <br /> Application of Desensitizing Resin for cervical <br /> D9911 and/or root surface per tooth $70.00 2013 <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 2015-16 Manager Recommended Fee Schedule <br />