| Type I – Preventive Dental Services |
 |
|
|
ADA
Code |
Procedure |
Maximum
Reimbursement |
 |
| 0120 |
Periodic Oral Evaluation (covered twice per 12
consecutive months) |
$21 |
 |
| 0210 |
Intraoral-Complete Series Including Bitewings
(Covered once per 3 year period) |
50 |
|
| 0220 |
Intraoral-Periapical-First Film |
10 |
|
| 0230 |
Intraoral-Periapical-Each Additional Film |
8 |
|
| 0240 |
Intraoral-Occlusal Film |
11 |
|
| 0250 |
Extraoral-First Film |
10 |
|
| 0260 |
Extraoral-Each Additional Film |
13 |
|
| 0270 |
Bitewings-Single Film (covered twice per 12
consecutive months) |
12 |
|
| 0272 |
Bitewings-Two Films (covered twice per 12
consecutive months) |
16 |
|
| 0274 |
Bitewings-Four Films (covered twice per 12
consecutive months) |
22 |
|
| 0290 |
Posterior/Anterior/Lateral Skull/Facial Bone Survey
Film |
43 |
|
| 0330 |
Panoramic Film (covered once per 3 year period) |
44 |
|
| 0415 |
Bacteriologic Studies (pathologic agents) |
13 |
|
| 1110 |
Prophylaxis-Adult (covered twice per 12 consecutive
months) |
32 |
|
| 1120 |
Prophylaxis-Child (covered twice per 12 consecutive
months) |
26 |
|
| 1201 |
Topical Fluoride application-CHILD (including
prophylaxis) (covered twice per 12 consecutive months, but only for
a dependent child under age 16) |
38 |
|
| 1203 |
Topical Fluoride Application-CHILD (excluding
prophylaxis) (covered twice per 12 consecutive months, but only for
a dependent child under age 16) |
13 |
|
| 1351 |
Sealant-Per Tooth (covered once per 12 consecutive
months for dependent child under age 13) |
16 |
|
| 1510 |
Space Maintainer-Fixed-Unilateral |
131 |
|
| 1515 |
Space Maintainer-Fixed-Bilateral |
231 |
|
| 1520 |
Space Maintainer-Removable-Unilateral |
170 |
|
| 1525 |
Space Maintainer-Removable-Bilateral |
200 |
|
| 1550 |
Recementation Of Space Maintainer |
32 |
|
| 7285 |
Biopsy Of Oral Tissue-Hard |
105 |
|
| 7286 |
Biopsy Of Oral Tissue-Soft |
105 |
|
| 9110 |
Palliative Treatment (covered as a separate
procedure only if no other service, except x-rays is rendered during
the visit) |
32 |
| |
