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Appendix A - Schedule of Covered Services and Copayments <br />Office Visit Copayments <br />General Office Visit Copayment $15 <br />Specialist Office Visit Copayment $30 <br />Code Procedure Enrollee Pays <br />1. Diagnostic and Preventive Services <br />D0120 Periodic oral evaluation - established patient <br />D0140 Limited oral evaluation - problem focused $0 <br />D0145 Oral evaluation for patient under 3 years of age and counseling with primary caregiver $0 <br />D0150 Comprehensive oral evaluation - new or established patient $0 <br />D0160 Detailed & extensive oral evaluation - problem focused, by report $0 <br />D0170 Re-evaluation - limited, problem focused (established patient not post -operative visit) $0 <br />D0180 Comprehensive periodontal evaluation - new or established patient $0 <br />D0210 Intraoral - complete series of radiographic images $0 <br />D0220 Intraoral - periapical-first radiographic image $0 <br />D0230 Intraoral - periapical each additional radiographic image $0 <br />D0240 Intraoral - occlusal radiographic image $0 <br />D0250 Extra -oral - 2D projection radiographic image $0 <br />D0270 Bitewing - single radiographic image $0 <br />D0272 Bitewings - two radiographic images $0 <br />D0273 Bitewings - three radiographic images $0 <br />D0274 Bitewings - four radiographic images $0 <br />D0277 Vertical bitewings - 7 to 8 radiographic images $0 <br />D0330 Panoramic radiographic image $0 <br />D0340 2D cephalometric radiographic image $0 <br />D0350 2D oral/facial photographic image obtained intraorally or extraorally $0 <br />D0425 Caries susceptibility tests $0 <br />D0460 Pulp vitality tests $0 <br />D0470 Diagnostic casts $0 <br />D1110 Prophylaxis - adult $0 <br />D1120 Prophylaxis - child $0 <br />D1206 Topical application of fluoride varnish $0 <br />D1208 Topical application of fluoride - excluding varnish $0 <br />D1310 Nutritional counseling for control of dental disease $0 <br />D1320 Tobacco counseling for the control and prevention of oral disease $0 <br />D1330 Oral hygiene instructions $0 <br />D1351 Sealant - per tooth $0 <br />D1510 Space maintainer - fixed unilateral - per quadrant $0 <br />D1516 Space maintainer fixed bilateral, maxillary $0 <br />D1517 Space maintainer fixed - bilateral, mandibular $0 <br />D1520 Space maintainer - removable - unilateral - per quadrant $0 <br />D1526 Space maintainer - removable - bilateral, maxillary $0 <br />D1527 Space maintainer - removable - bilateral, mandibular $0 <br />D1551 Re -cement or re -bond bilateral space maintainer - maxillary $0 <br />D1552 Re -cement or re -bond bilateral space maintainer - mandibular $0 <br />D1553 Re -cement or re -bond unilateral space maintainer - per quadrant $0 <br />D1556 Removal of fixed unilateral space maintainer - per quadrant $0 <br />D1557 Removal of fixed bilateral space maintainer maxillary $0 <br />D1558 Removal of fixed bilateral space maintainer - mandibular $0 <br />$0 <br />2. Restorative Services <br />D2140 Amalgam - 1 surface, primary or permanent $25 <br />Current Dental Terminology (CDT) 0 2020 American Dental Association. <br />All rights reserved. <br />001 L-WA811(5/20) 23 <br />