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Commissioner Approved Fee Schedule - FY 2018-19 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2018-19 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2018-19* <br />Last <br />Revision <br />ADA Code <br />Dental Health D0150 Comprehensive Oral Evaluation $80.00 2013 <br />Oral Evaluation for a patient under three years of <br />age and counseling with primary caregiver (26)$61.00 2015 <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 Bitewings- thre films $51.00 2013 <br />D0274 BWX 4 Films $58.00 2013 <br />D0220 1st Intraoral PA Film $26.00 2013 <br />D0230 Additional PA Film $23.00 2013 <br />D0240 Intraoral Occulusal Film $38.00 2013 <br />D0210 Full Mouth Series w BWX $120.00 2013 <br />D1120 Prophy/Child under age 13 $61.00 2013 <br />D1110 Prophy/Adult age 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 />D1206 <br />Topical Fluoride varnish;therapeutic application for <br />moderate to high caries risk patients $39.00 2013 <br />D1351 Sealant/NEWLY ERUPTED TEETH $49.00 2013 <br />Re-application of sealant $49.00 2015 <br />D4342 Scale/Root Planing 1-3 teeth p/q $167.00 2013 <br />D4341 Scale Root Planing 4> teeth p/q $231.00 2013 <br />D4346 <br />Scaling in presence of generalized moderate or <br />severe gingival inflammation $95.00 2017 <br />D4355 Full mouth Debridement $168.00 2013 <br />D4910 Periodontal Maintenance $127.00 2013 <br />D5411 Adjust Complete Denture - lower $0.00 $45.00 NEW <br />D6930 Recement Bridge $0.00 $100.00 NEW <br />D2140 Amal One Surface Prim/ Perm $130.00 2013 <br />D2150 Amal Two Surface Prim/ Perm $164.00 2013 <br />51