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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 $250600 2010 <br /> Shared Kitchen/Mobile Food Unit $ 100900 2018 <br /> Reinspection of Food Service Establishment $ 50 . 00 2018 <br /> Transitional Permit Plan Review $ 100000 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-evaluation4imited, problem $ 65 . 00 2013 <br /> D0210 Full Mouth Series w BWX $ 120400 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 $ 100000 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 /> Topical Fluoride varnish;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 /> D1354 SDF -Interim Caries Arresting Medicament $49 . 00 2018 <br /> D1510 Band & Loop/Quadrant Deliver 209/25 $287000 2013 <br /> D1515 Fixed Bilateral Deliver 419/30 $393600 2013 <br /> D1520 Space Maintainer-Removable, Unilateral $287. 00 2018 <br /> D1525 Space Maintainer-Removable, Bilateral $287400 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 $ 130600 2013 <br /> D2150 Amal Two Surface Prim/ Perm $ 164000 2013 <br /> D2160 Amal Three Surface Prim/Perm $ 198000 2013 <br /> D2161 Amal Four Surface Prim/Perm $236000 2013 <br /> D2330 Resin One Surface Anterior $ 148000 2013 <br /> D2331 Resin Two Surface Anterior $ 183 . 00 2013 <br /> D2332 Resin Three Surface Anterior $227000 2013 <br /> D2335 Resin Four Surface Anterior $288000 2013 <br /> D2390 Resin Comp . Crown Ant. Prim $414600 2013 <br /> D2391 Resin Comp . 1sur.Post-Prim/Perm $ 162600 2013 <br /> D2392 Resin Comp . 2sur.Post-Prim/Perm $212000 2013 <br /> D2393 Resin Comp . 3sur.Posterior Perm $261 . 00 2013 <br /> D2394 IResin Comp .4+sur.Posterior Perm $314. 00 12013 <br />