| Code |
Description |
Enrollee Pays |
| D1110 |
Prophylaxis cleaning - adult - 1 per 6 month period |
$ 25 |
| D1120 |
Prophylaxis cleaning - child - 1 per 6 month period |
$ 25 |
| D1203 |
Topical application of fluoride (prophylaxis not included) - child - to age 19; 1 per 6 month period |
$ 20 |
| D1206 |
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients – child to age 19; 1 per 6 month period |
$ 20 |
| D1330 |
Oral hygiene instructions |
No Cost |
| D1351 |
Sealant - per tooth - limited to permanent molars through age 15 |
$ 20 |
| D1510 |
Space maintainer - fixed - unilateral |
$100 |
| D1515 |
Space maintainer - fixed - bilateral |
$150 |
| D1520 |
Space maintainer - removable - unilateral |
$100 |
| D1525 |
Space maintainer - removable - bilateral |
$150 |
| D1550 |
Re-cementation of space maintainer |
$ 10 |
| D1555 |
Removal of fixed space maintainer |
$ 10 |
