3018. NEIGHBORHOOD HEALTH CLINIC FEES

3018 NEIGHBORHOOD HEALTH CLINIC FEES 3018.1 The following fees shall be for the services provided by the Neighborhood Health Centers, and shall have the sliding fee scale, set forth at §3018.2, for patients who are not covered by Medicaid, Medicare, or any other third party insurance and whose annual gross family incomes fall within the ranges of the sliding scale. These rates shall not apply to those persons who are receiving assistance under title VII of the D.C. Public Assistance Act of 1982, D.C. Code, 2001 Ed. §§4-207.01 to 4-207.04, and who do not receive assistance under Medicaid: Service Category Fee Acrylic or Plastic Restoration Acrylic or plastic restoration, Class III $ 16.00 Acrylic or plastic restoration, Class V 12.00 Esthetic restoration, including angle 20.00 Alveoloplasty (surgical preparation of ridge for dentures) Alveolectomy with extraction $ 55.00 Alveolectomy without extraction 75.00 Cardiology Follow-up visit 25.00 Initial visit 75.00 Crowns - Single Restoration Only Acrylic jacket 72.00 Dowel crown 120.00 Gold full cast 94.00 Stainless steel crown 31.00 Temporary crown 17.00 Veneer crown 94.00 Dental - Diagnostic Full mouth x-ray series 22.00 Occlusal x-ray 8.00 Periapical x-ray, one film 4.00 Periapical x-ray, two films 7.00 Periapical x-ray, three films 8.00 Endodontics Pulp capping 8.00 Pulpotomy 16.00 Root Canal One Canal; excludes final restoration 75.00 Two Canals; excludes final restoration 96.00 Three Canals; excludes final restoration 116.00 Family Planning Follow-up visit 40.00 General Medicine Follow-up /return/acute care visit 40.00 Initial visit (comprehensive medical evaluation 75.00 including complete history, review of medical records, complete physical examination, laboratory testing and appropriate prescriptions) Nursing Home Visit 32.25 Obstetrics/Gynecology Acute care visit $ 40.00 Follow-up visit 40.00 Initial visit 60.00 Oral Surgery Complicated extraction Extraction of tooth, erupted 30.00 Extraction of tooth, soft tissue impaction 45.00 Extraction of tooth, partial bony impaction 59.00 Extraction of tooth, complete bony impaction 65.00 Root tips 25.00 Simple extraction (per tooth) 11.50 Surgical exposure of bony impaction 45.00 Other Restorative Services 10.00 Orthodontics Appliances to control harmful habits 75.00 Pediatrics Acute care visit 40.00 Adolescent or athletic exam 50.00 Follow-up visit 40.00 Periapical Services Apicoectomy 52.00 Periapical curettage 34.00 Periodontics Adjunctive services Deep scaling 25.00/quad Advanced periodontitis Vincents treatment 50.00 Nonsurgical services Subgingival curettage, root 50.00/quad Surgical services Gingivectomy or gingivoplasy 100.00/quad Podiatry Follow-up visit 20.00 Initial visit/comprehensive 40.00 Postpartum OB Follow-up visit 40.00 Acute 40.00 Prenatal OB Follow-up/Returns $ 40.00 Acute 40.00 Preventive Dental Prophylaxis Prophylaxis, mouth exam, fluoride application, bitewings, oral hygiene instruction 25.00 Prophylaxis, under age 15 7.00 Prophylaxis, age 15 and over 10.00 Florida treatment 8.00 Space maintainers Fixed, band type 75.00 Lingual archwire 75.00 Space maintainer, removable 59.00 Prostodontics Additional clasps for partial dentures 25.00 Adjustment denture 10.00 Complex denture repair 35.00 Full denture1 100.00 Partial denture1 150.00 Simple denture repair 12.00 1 This fee represents the maximum charge for this service regardless of the number of treatment sessions required to complete dentures plus two (2) visits for adjustments. Prosthodontics, Fixed Amalgam build-up 35.00 Reduction of Dislocation 60.00 Restorative Amalgam restoration (including polishing) Amalgam restorative pit, one surface 6.00 Amalgam restoration, two pits 9.00 Amalgam one surface, deciduous 10.00 Amalgam two surfaces, deciduous 14.00 Amalgam three surfaces 21.00 Amalgam four surfaces 27.00 Amalgam one surface, permanent 10.00 Amalgam two surfaces, permanent 14.00 Amalgam three surfaces, permanent 21.00 Amalgam four surfaces, permanent $ 27.00 Pin reinforced 6.00 Specialized Clinics Physician services - comprehensive 50.00 (comprehensive medical evaluation, diagnosis and treatment for allergic, ophthalmologic and dermatologic complaints) Physician services - Limited 25.00 (Re-evaluation and treatment for a special complaint as defined above) Services performed by ancillary professionals 20.00 not under the supervision of the physician such as nutritional and social work counseling services Specialized Services Allergy F-U 40.00 Chest F-U 40.00 Dermatology F-U 40.00 Hearing F-U 40.00 Occ. Therapy F-U 40.00 Ophthalmo F-U 40.00 Psych. F-U 40.00 Phys. Therapy F-U 40.00 Speech F-U 40.00 Surgical Incision Curettage of fistulous tract 15.00 Incision/Drainage abscess intraoral 25.00 Incision/Drainage, extraoral 65.00 3018.2 The sliding fee schedule applicable to self-pay patients for the services described in §3018.1 and certain other services provided by the Department of Human Services shall be as follows: Department of Human Services Sliding Fee Schedule Category A B C D E F Family Size Pay 0% of Full Charge Pay 20% of Full Charge Pay 40% of Full Charge Pay 60% of Full Charge Pay 80% of Full Charge Pay 100% of Full Charge* 1 0 to 4,860 4,861 - 6,895 6,896 - 8,930 8,931 - 10,965 10,966 -13,000 13,000 2 0 to 6,540 6,541 - 9,811 9,812 - 11,282 11,283 - 13,653 13,654 - 16,024 16,024 3 0 to 8,220 8,221 -10,927 10,928 - 13,634 13,635 - 16,341 16,342 - 19,048 19,048 4 0 to 9,900 9,901 - 12,943 12,944 - 15,986 15,987 - 19,029 19,030 - 22,072 22,072 5 0 to 11,580 11,581 - 14,959 14,960 -18,338 18,339 - 21,717 21,718 - 25,096 25,096 6 0 to 13,260 13,261 - 16,975 16,976 - 20,690 20,691 - 24,405 24,406 - 28,120 28,120 7 0 to 14,940 14,941 - 18,991 18,992 - 23,042 23,043 - 27,093 27,094 - 31,144 31,144 8 0 to 16,620 16,621 - 21,007 21,008 - 25,394 25,395 - 29,781 29,782 - 34,168 34,168 9 0 to 18,300 18,301 - 23,023 23,024 - 27,746 27,747 - 32,469 32,470 - 37,192 37,192 10 0 to 19,980 19,981 - 25,039 25,040 - 30,098 30,099 - 35,157 35,158 - 40,216 40,216 11 0 to 21,660 21,661 - 27,055 27,056 - 32,450 32,451 - 37,845 37,846 - 43,240 43,240 12 0 to 23,340 23,341 - 29,071 29,072 - 34,802 34,803 - 40,533 40,534 - 46,264 46,264 * Pay 100% of full charge if income is greater than the amount indicated in this column. AUTHORITY: Sections 3018 and 3019 were originally enacted under the authority of the D.C. Code, 2001 Ed. § 44-786. Subsequent to the enactment of these sections, § 44-786 was repealed by D.C. Law 5-173, 32 DCR 736 (March 15, 1985). For current provisions authorizing the Mayor to establish fees for clinical services, please refer to D.C. Code, 2001 Ed. §44-731. SOURCE: Final Rulemaking published at 31 DCR 346 (January 27, 1984); as amended by Final Rulemaking published at 40 DCR 6262 (August 27, 1993). EDITOR’S NOTE: Title VII of the District of Columbia Public Assistance Act of 1982, D.C. Code, 2001 Ed. §§4-207.01 to 4-207.04, referenced in § 3018.1, was repealed by D.C. Law 10-253 § 502(f).