Page 29 - Demo

DiagnosticD0120 Periodic oral evaluation %u2014 established patient %u2014 twice within a 12-month period $0D0120 Additional periodic oral evaluation %u2014 established patient (within the 12-month period) $30D0140 Limited oral evaluation %u2014 problem focused $0D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0D0150 Comprehensive oral evaluation %u2014 new or established patient $0D0160 Detailed and extensive oral evaluation %u2014 problem focused, by report $0D0170 Re-evaluation %u2014 limited, problem focused (established patient; not post-operative visit) $0D0171 Re-evaluation %u2014 post-operative office visit $0D0180 Comprehensive periodontal evaluation %u2014 new or established patient $0D0190 Screening of a patient $0D0191 Assessment of a patient $0D0210 Intraoral %u2014 complete series of radiographic images %u2014 limited to 1 series every five years $0D0220 Intraoral %u2014 periapical first radiographic image $0D0230 Intraoral %u2014 periapical each additional radiographic image $0D0240 Intraoral %u2014 occlusal radiographic image $0D0250 Extraoral %u2014 2D projection radiographic image created using a stationary radiation source and detector $0D0251 Extraoral posterior dental radiographic image $0D0270 Bitewing %u2014 single radiographic image $0D0272 Bitewings %u2014 two radiographic images $0D0273 Bitewings %u2014 three radiographic images $0D0274 Bitewings %u2014 four radiographic images %u2014 limited to 1 series in 12 months $0D0277 Vertical bitewings %u2014 7 to 8 radiographic images $0D0330 Panoramic radiographic image $0D0415 Collection of microorganisms for culture and sensitivity $0D0425 Caries susceptibility tests $0D0460 Pulp vitality tests $0D0470 Diagnostic casts $0D0473 Accession of tissue, gross and microscopic examination, preparation, and transmission of written report $0D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation, and transmission of written report$0D0601 Caries risk assessment and documentation, with a finding of low risk %u2014 1 every 3 years $0D0602 Caries risk assessment and documentation, with a finding of moderate risk %u2014 1 every 3 years $0D0603 Caries risk assessment and documentation, with a finding of high risk %u2014 1 every 3 years $0D0999 Unspecified diagnostic procedure, by report %u2014 includes office visit, per visit (in addition to other services) $0PreventiveD1110 Prophylaxis cleaning %u2014 adult %u2014 1 D1110, D1120 or D4346 twice per 12-month period $0D1110 Additional prophylaxis cleaning %u2014 adult (within the 12-month period) $60D1120 Prophylaxis cleaning %u2014 child %u2014 1 D1110, D1120 or D4346 twice per 12-month period $0D1120 Additional prophylaxis cleaning %u2014 child (within the 12-month period) $49D1206 Topical application of fluoride varnish %u2014 child to age 19; 1 D1206 or D1208 per six-month period $0D1208 Topical application of fluoride %u2014 excluding varnish %u2014 child to age 19; 1 D1206 or D1208 per six-month period $0D1310 Nutritional counseling for control of dental disease $0D1330 Oral hygiene instructions $0D1351 Sealant %u2014 per tooth %u2014 limited to permanent molars through age 15 $15D1352 Preventive resin restoration in a moderate to high caries risk patient %u2014 permanent tooth %u2014 limited to permanent molars through age 15$20D1353 Sealant repair %u2014 per tooth %u2014 limited to permanent molars through age 15 $15D1354 Interim caries arresting medicament application %u2014 child to age 19; 1 per six-month period $0D1510 Space maintainer %u2014 fixed %u2014 unilateral $60D1515 Space maintainer %u2014 fixed %u2014 bilateral $60D1520 Space maintainer %u2014 removable %u2014 unilateral $60D1525 Space maintainer %u2014 removable %u2014 bilateral $60D1550 Re-cement or re-bond space maintainer $0D1555 Removal of fixed space maintainer $0D1575 Distal shoe space maintainer %u2014 fixed %u2014 unilateral %u2014 child to age 9 $0PRIMARY SERVICES %u2014 Primary services are covered if necessary and performed by your attending Plan Dentist subject to the limitations, exclusions, and governing administrative policies of the program.PROCEDURE ENROLLEE CODES COPAYMENTSDental Benefits Program: Flagship NJ124(A) Plan51+ Enrolled Employees Benefit Summary29