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Manager Recommended Fee Schedule - FY 2022-23 40 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> Food Service <br /> Plan review and permit fee-Temporary Food <br /> Establishment $75.00 2010 <br /> Plan Review-Food Service Establishment $250.00 2010 <br /> Shared Kitchen/Mobile Food Unit $100.00 2018 <br /> Reinspection of Food Service Establishment $50.00 2018 <br /> Transitional Permit Plan Review $100.00 2018 <br /> Mobile Food Unit Plan Review $150.00 2022 <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 IBWX 4 Films $58.00 2013 <br /> D0330 Panoramic Film $100.00 2013 <br /> D0470 Study Models $104.00 2013 <br /> D 1110 Prophy/Adult age 13 and up $82.00 2013 <br /> D 1120 Prophy/Child under age 13 $61.00 2013 <br /> D1203 Fluoride Varnish(age 13&under) $33.00 2013 <br /> D1204 lFluoride Varnish(age 13-20) $33.00 2013 <br /> Topical Fluoride vamish;therapeutic application for <br /> D 1206 moderate to high caries risk patients $39.00 2013 <br /> D1351 Sealant/NEWLY ERUPTED TEETH $49.00 2013 <br /> D 1354 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 1$314.00 2013 <br />