| Code |
Description |
Enrollee Pays |
| D0120 |
Periodic oral evaluation - established patient |
No Cost |
| D0140 |
Limited oral evaluation - problem focused |
No Cost |
| D0145 |
Oral evaluation for a patient under three years of age and counseling with primary caregiver |
No Cost |
| D0150 |
Comprehensive oral evaluation - new or established patient |
No Cost |
| D0160 |
Detailed and extensive oral evaluation - problem focused, by report |
No Cost |
| D0170 |
Re-evaluation - limited, problem focused (established patient; not post-operative visit) |
No Cost |
| D0180 |
Comprehensive periodontal evaluation - new or established patient |
No Cost |
| D0210 |
Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months |
No Cost |
| D0220 |
Intraoral - periapical first film |
No Cost |
| D0230 |
Intraoral - periapical each additional film |
No Cost |
| D0240 |
Intraoral - occlusal film |
No Cost |
| D0270 |
Bitewing radiograph - single film |
No Cost |
| D0272 |
Bitewings radiographs - two films |
No Cost |
| D0273 |
Bitewings radiographs - three films |
No Cost |
| D0274 |
Bitewings radiographs - four films - limited to 1 series every 6 months |
No Cost |
| D0330 |
Panoramic film |
No Cost |
| D0460 |
Pulp vitality tests |
No Cost |
| D0470 |
Diagnostic casts |
No Cost |
| D0472 |
Accession of tissue, gross examination, preparation and transmission of written report |
No Cost |
| D0473 |
Accession of tissue, gross and microscopic examination, preparation and transmission of written report |
No Cost |
| D0474 |
Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report |
No Cost |
| D0999 |
Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services) |
$ 5 |
