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Commissioner Approved Fee Schedule - FY 2019-20 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2019-20 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2019-20* <br />Last <br />Revision <br />ADA Code <br />Dental Health D0120 Periodic Oral Evaluation $45.00 2013 <br />D0140 Limited Oral Evaluation $69.00 2013 <br />D0150 Comprehensive Oral Evaluation $80.00 2013 <br />D0170 Re-evaluation-limited, problem $65.00 2013 <br />D0210 Full Mouth Series w BWX $120.00 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 />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 />D0330 Panoramic Film $100.00 2013 <br />D0470 Study Models $104.00 2013 <br />D1110 Prophy/Adult age 13 and up $82.00 2013 <br />D1120 Prophy/Child under age 13 $61.00 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 />D1354 SDF-Interim Caries Arresting Medicament $49.00 2018 <br />D1510 Band & Loop/Quadrant Deliver 209/25 $287.00 2013 <br />D1515 Fixed Bilateral Deliver 419/30 $393.00 2013 <br />D1520 Space Maintainer-Removable, Unilateral $287.00 2018 <br />D1525 Space Maintainer-Removable, Bilateral $287.00 2018 <br />D1550 Recementation of Space Maintainer $57.00 2018 <br />D1555 Removal of Fixed Space Maintainer $25.00 2018 <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 />52