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• <br /> • Attachment One <br /> 2 1 . PROPOSED DENTAL . PROGRAM FEES <br /> July 1, 1986 <br /> Present 1002 Recommended RecomMended Fee <br /> Procedure pay fee 100X pay fee at 20Z pay level <br /> Screening/Emergency Exam $5.00 $10.00 $2.00 <br /> Clinical Exam $15.00 20.00 4.00 <br /> Consultation 5.00 10.00 2.00 <br /> X-Ray, Panelipse ' 25.00 30.00 6.00 <br /> FMX - No BWX 25.00 40.00 8.00 <br /> BWX 1 6.00 7.00 1.40 <br /> BWX 2 . - 8.00 9.00 1.80 <br /> BWX 3 10.00 12.00 2.40 <br /> BWX 4 12.00 15.00 3.00 <br /> let Intraaral PAX 6.00 8.00 1.60 <br /> Additional PAX-Ray 3.00 4.00 80 <br /> Iatraoral 0ccl Film 8:00 10.00 2.00 <br /> Prophylaxis - Child 15.00 20.00 4.00 <br /> Adult 15.00 25.00 5.00 <br /> Gross Scaling 20.00 25.00 5.00 <br /> Topical Fluoride • 8.00 12.00 2.40 <br /> Dental Oral Hygiene 10.00 15.00 3.00 <br /> Amalgam, 1 Surface 15.00 20.00 4.00 <br /> 2 Surface 25.00 35.00 . 7.00 <br /> 3 Surface 30.00 40.00 8.00 <br /> 4 Surface 40.00 45.00 9.00 <br /> 5 Surface 50.00 55.00 11.00 <br /> Composite:l Surface 15.00 25.00 5.00 <br /> 2 Surface 25.00 35.00 7.00 <br /> 3 Surface 30.00 40.00 - 8.00 <br /> 4 Surface 45.00 50.00 10.00 <br /> Treatment Restoration 15.00 25.00 5.00 <br /> Pin Build-up (each) 5.00 10.00 2.00 <br /> Para Post 60.00 75.00 15.00 <br /> St St Crown 50.00 65.00 13•.00 <br /> Sealant (per quadrant) 20.00 30.00 6.00 <br /> Palliative Treatment 10:00 15.00 3.00 <br /> Premedication 10.00 35.00 7.00 <br /> Recemeating 10.00 25.00 5.00 <br /> Study Models 20.00 30.00 6.00 <br /> Extraction (Prim) 15.00 25.00 5.00 <br /> Extraction (Perm) 25.00 35.00 7.00 <br /> Extraction (Surg) 50.00+ 65.00+ 13.00+ <br /> Post-op Visit N/A 10.00 2.00 <br /> I&D, Minor Surgery 10.00 25.00 5.00 <br /> Pulpotomy 45.00 50.00 <br /> = Fractured Tooth Treatment 10.00 <br /> ",r 50.00+ 10.00+ <br /> Endodontics - 1 Root 90.00 115.00 23.00 <br /> 2 Roots 125.00 150.00 30.00 <br /> 3 Roots 150.00 225.00 . 45.00 <br /> Occlusal Equilib 8.00 15.00 3.00 <br /> Periodontal Exam 15.00 25.00 5.00 <br /> Perio Surgery (per quad) 25.00 75.00 15.00 <br /> Perio Scaling & Root 25.00 40.00 8.00 <br /> Planing (per quad) <br /> Duplicating X-Rays 2.00 5.00." 1.00 <br /> PROCEDURES WITH ADDITIONAL FEE FOR LAB WORK <br /> Full Denture 225.00 275.00 55.00 <br /> Immed. Full Denture 250.00 300.00 60.00 <br /> Partial Denture 130.0t) 275.00 55.00 <br /> Cast Part Denture 250.00 350.00 70.00 <br /> Denture Reline 30.00 150.00 30.00 <br /> `Z: Denture Repairs 20.00+ 30.00+ 6.00+ <br /> • Biopsy Oral Tissue 20.00 30.00 6.00 <br /> `. Space Maintainers <br /> Band 5 Loop (per quad)30.00 60.00 12.00 <br /> Distal Shoe (perquad) 50.00 75.00 15.00 <br /> St St Crown Type 68.00 85.00 17.00 <br /> Lingual Arch 75.00 125.00 25.00 <br /> Removable 125.00 150.00 30.00 <br /> Removable Repairs 10.00 25.00 5.00 <br /> Habit Appliance 75.00 125.00 25.00 <br /> 1 - No patient will be denied alleviation of pain due to inability to pay. <br /> 2 - The minimum fee per appointment is recommended to be increase from $5 to $8. <br /> . . _.. -.1..- <br />