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54 <br /> Commissioner Approved <br /> Fee Changes for Last <br /> Department/Program Description Current Fee FY 2021-22* Revision <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 /> 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. Isur.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 Comp.4+sur.Posterior Perm $314.00 2013 <br /> D2920 Recement Crown NOT cov.by MA $100.00 2013 <br /> D2930 SSC Primary Tooth $247.00 2013 <br /> D2931 SSC Permanent Tooth $298.00 2013 <br /> D2932 Prebacricated Resin Crown $323.00 2013 <br /> D2934 Prefab.est.coat SSC prim.Tooth $327.00 2013 <br /> D2940 Sedative Filling $113.00 2013 <br /> D2951 Pin Retention/tooth $67.00 2012 <br /> D3110 Pulp Cap-direct exp.Pulp MED $76.00 2013 <br /> D3120 Pulp Cap-indirect nearly exposed $77.00 2013 <br /> D3220 Pulpotomy $183.00 2013 <br /> D3310 Root Canal Therapy Anterior $676.00 2013 <br /> D3320 Root Canal Therapy Bicuspid $780.00 2013 <br /> D3330 Root Canal Therapy Molar $943.00 2013 <br /> D4320 Provisional Splinting,intracoronal $115.00 2017 <br /> D4321 Provisional Splinting,extracoronal $115.00 2017 <br />