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SAMPLE DENTAL FEES <br /> CHARGED pR0}wEDURE <br /> EXAM X-RAY FLU0IRIDE EXTRACTTQN T-1-CLING <br /> 100 $15.00 $23.00 $3.00 $13.00 $13-00 <br /> 80 12.00 18.40 6.40 10.40 10.140 <br /> 60 9.00. 1,3.80 4.80 7.80 7.80 <br /> 40 6.00 9.20 3.20 5.20 5.20 <br /> 20 3.00 4.60 1.6D ! 2.60 2.60 <br /> 15 <br /> 2.25 3.45 1.20 ± 1.95 1.95 <br /> Under Medicaid, patients pay a $1.00 fee no matter what service is rendered. <br /> NORTjj CAROLINA STATEIRIDE FAMILY PLANNING PROGRAM <br /> PATIENT FEES (REVISED AS OF JULY 11 1980) <br /> °n CNRp INITIAL OR ANNUAL VISIT E�4EDICAL �r1ITH PELVIC VISIT MEDICAL tlTTci�Ji7T PE <br /> 15 $9.00 $3.00 <br /> 2.00 <br /> � 20 I2.DO 4.00 <br /> 9.00 5.00 <br /> 40 25.00 <br /> 60 37.00 13.00 7.00 <br /> $0 50.00 18.00 10.00) <br /> 100 <br /> 6z.00 23.00 12.00 <br /> 1 <br /> s <br /> i <br /> i <br />