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Dallas
Independent School
District Dental Member |
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Texas Dental Plan (TDP) Schedule1
| 1Select a
service below |
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| SERVICES |
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DIAGNOSTIC AND PREVENTIVE DENTISTRY |
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ADA
Code |
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Procedure |
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Member
Pays |
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D0120 |
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Periodic oral examination |
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15 |
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D0150 |
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Comprehensive oral evaluation |
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15 |
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D0210 |
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Intraoral - complete series (including bitewings) |
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30 |
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D0220 |
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Intraoral - periapical (first film) |
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5 |
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D0230 |
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Intraoral - periapical (each additional film) |
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4 |
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D0270 |
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Bitewing - single film |
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5 |
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D0330 |
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Panoramic films |
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30 |
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D0460 |
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Pulp vitality tests |
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12 |
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D0470 |
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Diagnostic casts |
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20 |
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D1110 |
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Prophylaxis - adult |
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29 |
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D1120 |
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Prophylaxis - child |
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29 |
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D1351 |
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Sealant per tooth |
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20%
Discount |
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(Patients who have not had regular cleanings may require gum treatment) |
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D4355 |
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Full mouth debridement to enable comprehensive periodontal evaluation and
diagnosis |
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45 |
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D9310 |
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Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment) |
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15/10
-Ortho |
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D9999 |
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Infection control fee** |
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9 |
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**Infection control guidelines have been established by OSHA and the
American Dental Association. Infection control measures will be charged
routinely by a participating dental office. |
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All of the listed charges are reduced fees for services
performed by a participating general dentist. Fees are
subject to change without notice.
Any procedure not listed is available on a fee for service basis at
a 20% discount. Consult with your participating general dentist
prior to beginning any treatment. |
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Specialist Services
Any treatment provided by a participating specialist, if available,
in Endodontics (root canal), Pediatric Dentistry (children's
dentistry), Prosthodontics (Dentures), Orthodontics (teeth
straightening), Periodontics (gum disease treatment) or Oral
Surgery, will be charged at a 20% reduction of participating
specialist's fees for that particular case. Some specialists may
require a consultation visit before treatment is initiated. Discuss
each case with the specialist prior to beginning any treatment. |
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