| Code | Procedure | Patient will pay: |
| Diagnostic | ||
| D0120 | Periodic oral examination – established patient (once every 6 consecutive months) |
$0
|
| D0140 | Limited oral evaluation – problem focused (no separate benefit will be paid if definitive treatment was performed within prior 30 days). Only two occurrences allowed in 12 months with the same dental office |
0
|
| D0145 | Oral evaluation for a patient under 3 years of age and counseling with primary caregiver, once every 6 consecutive months until age 3 |
0
|
| D0150 | Comprehensive oral evluation – new or existing patient once every 60 consecutive months per dental office |
0
|
| D0160 | Detailed and extensive oral evaluation – problem focused, by report |
0
|
| D0170 | Re-evaluation – limited problem focused, by report |
0
|
| D0171 | Re-evaluation – post-operative visit | 0 |
| D0180 | Comprehensive periodontal evaluation – new or established patient once every 60 consecutive months per dental office |
0
|
| D0210 | Intraoral X-rays, complete series once every 60 months | 0 |
| D0220 | Intraoral periapical X-ray, first film |
0
|
| D0230 | Intraoral periapical X-ray, each additional film |
0
|
| D0240 | Intraoral – occlusal film |
0
|
| Bitewing X-rays, once every 6 consecutive months for dependents age 18 and under, once every 12 months for adults (not allowed less than 6 months after full mouth series | ||
| D0270 | Bitewing single film |
0
|
| D0272 | Bitewings two films |
0
|
| D0273 | Bitewings three films |
0
|
| D0274 | Bitewings four films |
0
|
| D0277 | Vertical bitewings – 7 to 8 films |
0
|
| D0330 | Panoramic film, once every 60 months |
0
|
| D0364 | Cone beam CT – less than one whole jaw, once every 12 months | 0 |
| D0365 | Cone beam CT – mandible, once every 12 months | 0 |
| D0366 | Cone beam CT – maxilla, with/without cranium, once every 12 months | 0 |
| D0367 | Cone beam CT – both jaws, with/without cranium, once every 12 months | 0 |
| D0460 | Pulp vitality tests | 0 |
| Preventive | ||
| D1110 | Prophylaxis (cleaning) adult, once every 6 consecutive months | 0 |
| D1120 | Prophylaxis (cleaning) child, under age 14, once every 6 consecutive months | 0 |
| D1206 | Topical fluoride varnish, therapeutic application for moderate to high caries risk patients, payable up to 4 times per year | 0 |
| D1208 | Topical application of fluoride, payable up to 4 times per year | 0 |
| D1351 | Sealant per tooth, only on unrestored permanent molars, once every 48 months for patients age 18 and under | 0 |
| D1352 | Preventive resin restoration in a moderate to high risk patient – permanent tooth, once every 48 months | 0 |
| D1354 | Interim caries arresting medicament application – per tooth | 0 |
| Space maintainers, once per quadrant, per lifetime, age 14 and under | ||
| D1510 | Space maintainer – fixed unilateral | 0 |
| D1516/1517 | Space maintainer – fixed bilateral, maxillary/mandibular | 0 |
| D1520 | Space maintainer – removable unilateral | 0 |
| D1526/1527 | Space maintainer – removable bilateral, maxillary/mandibular | 0 |
| D1551/1552 | Re-cementation of space maintainer, maxillary/mandibular, once per appliance per lifetime | 0 |
| D1553 | Re-cement or re-bond unilateral space maintainer, per quadrant, once per appliance per lifetime | 0 |
| D1556 | Removal of fixed bilateral space maintainer, per quadrant, once per lifetime per appliance | 0 |
| D1557/1558 | Removal of fixed bilateral space maintainer, maxillary/mandibular, once per lifetime per appliance | 0 |
| D1575 | Distal shoe space maintainer – fixed – unilateral | 0 |
| D1999 | Prescription fluoride toothpaste | 0 |
| D1999 | Chlorhexidine | 0 |
| D2991 | Application of hydroxyapatite regeneration medicament, per tooth | 0 |
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation | 0 |
| D4910 | Periodontal maintenance, once ever 3 months following active periodontal treatment | 0 |
* For example, if you have an examination and cleaning on July 15, 2024 you may not have another covered examination or cleaning until January 15, 2025.