D.C. Mun. Regs. tit. 22, r. 22-B3018
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 |
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.
D.C. Mun. Regs. tit. 22, r. 22-B3018