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| SAMPLE OFFICE VISITS |
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Code |
Procedure |
Enrollee Pays |
| Sample visit #1 |
D0999 |
Office visit |
$ 5.00 |
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D0150 |
Comprehensive oral exam |
No Cost |
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D0210 |
X-rays |
No Cost |
| TOTAL |
$ 5.00 |
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| Sample visit #2 |
D0999 |
Office visit (6 month checkup) |
$ 5.00 |
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D0160 |
Detailed oral exam |
No Cost |
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D0210 |
X-rays (if needed) |
No Cost |
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D1110 |
Prophylaxis - adult |
$ 20.00 |
| TOTAL |
$ 25.00 |
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| Sample visit #3 |
D0999 |
Office visit |
$ 5.00 |
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D0160 |
Detailed oral exam |
No Cost |
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D0210 |
X-rays |
No Cost |
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D7111 |
Single tooth extraction |
$ 30.00 |
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D9215 |
Local anesthetic |
No Cost |
| TOTAL |
$ 35.00 |
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| Sample visit #4 |
D0999 |
Office visit |
$ 5.00 |
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D2140 |
One surface amalgam filling |
$ 27.00 |
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D2330 |
One surface resin filling |
$ 55.00 |
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D9215 |
Local anesthetic |
No Cost |
| TOTAL |
$ 87.00 |
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| Sample visit #5 |
D0999 |
Office visit |
$ 5.00 |
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D0160 |
Detailed oral exam |
No Cost |
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D2791 |
Crown – full cast predominantly base metal * |
$ 310.00 |
| TOTAL |
$ 315.00 |
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| *May require build-up at additional cost. |
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