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| Dallas Independent School
District Dental Member | | | | | | | | | | | | | | | | | | | | |
Texas Dental Plan (TDP) Schedule1
| 1Select a service below | | | | SERVICES | | | | | | | | | | | | | | | | DIAGNOSTIC AND PREVENTIVE DENTISTRY | | | | | | | ADA
Code | | Procedure | | Member
Pays |  | | D0120 | | Periodic oral examination | | 15 | | | | D0150 | | Comprehensive oral evaluation | | 15 | | | | D0210 | | Intraoral - complete series (including bitewings) | | 30 | | | | D0220 | | Intraoral - periapical (first film) | | 5 | | | | D0230 | | Intraoral - periapical (each additional film) | | 4 | | | | D0270 | | Bitewing - single film | | 5 | | | | D0330 | | Panoramic films | | 30 | | | | D0460 | | Pulp vitality tests | | 12 | | | | D0470 | | Diagnostic casts | | 20 | | | | D1110 | | Prophylaxis - adult | | 29 | | | | D1120 | | Prophylaxis - child | | 29 | | | | D1351 | | Sealant per tooth | | 20%
Discount | | | | | | (Patients who have not had regular cleanings may require gum treatment) | | | | D4355 | | Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis | | 45 | | | | D9310 | | Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | | 15/10
-Ortho | | | | D9999 | | Infection control fee** | | 9 | | | | | | **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. | | | 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. | | | 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. | | | |
