EPN Paid-in-Full Services

 

 Code Procedure Patient will pay:
Diagnostic 
D0120 Periodic oral examination – established patient (once every 6 consecutive months)
$0
D0140 Limited oral evaluation – problem focused (no separate benefit will be paid if definitive treatment was performed within prior 30 days). Only two occurrences allowed in 12 months with the same dental office
0
D0145 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver, once every 6 consecutive months until age 3
0
D0150 Comprehensive oral evluation – new or existing patient once every 60 consecutive months per dental office
0
D0160 Detailed and extensive oral evaluation – problem focused, by report
0
D0170 Re-evaluation – limited problem focused, by report
0
D0171 Re-evaluation – post-operative visit 0
D0180 Comprehensive periodontal evaluation – new or established patient once every 60 consecutive months per dental office
0
D0210 Intraoral X-rays, complete series once every 60 months 0
D0220 Intraoral periapical X-ray, first film
0
D0230 Intraoral periapical X-ray, each additional film
0
D0240 Intraoral – occlusal film
0
Bitewing X-rays, once every 6 consecutive months for dependents age 18 and under, once every 12 months for adults (not allowed less than 6 months after full mouth series
D0270 Bitewing single film
0
D0272 Bitewings two films
0
D0273 Bitewings three films
0
D0274 Bitewings four films
0
D0277 Vertical bitewings – 7 to 8 films
0
D0330 Panoramic film, once every 60 months
0
D0460 Pulp vitality tests 0
Preventive 
D1110 Prophylaxis (cleaning) adult, once every 6 consecutive months 0
D1120 Prophylaxis (cleaning) child, under age 14, once every 6 consecutive months 0
D1206 Topical fluoride varnish, therapeutic application for moderate to high caries risk patients, payable up to 4 times per year 0
D1208 Topical application of fluoride, payable up to 4 times per year 0
D1351 Sealant per tooth, only on unrestored permanent molars, once every 48 months for patients age 18 and under 0
D1352 Preventive resin restoration in a moderate to high risk patient – permanent tooth, once every 48 months 0
D1354 Interim caries arresting medicament application – per tooth 0
Space maintainers, once per quadrant, per lifetime, age 14 and under
D1510 Space maintainer – fixed unilateral 0
D1516/1517 Space maintainer – fixed bilateral, maxillary/mandibular 0
D1520 Space maintainer – removable unilateral 0
D1526/1527 Space maintainer – removable bilateral, maxillary/mandibular 0
D1551/1552 Re-cementation of space maintainer, maxillary/mandibular, once per appliance per lifetime 0
D1553 Re-cement or re-bond unilateral space maintainer, per quadrant, once per appliance per lifetime 0
D1556 Removal of fixed bilateral space maintainer, per quadrant, once per lifetime per appliance 0
D1557/1558 Removal of fixed bilateral space maintainer, maxillary/mandibular, once per lifetime per appliance 0
D1575 Distal shoe space maintainer – fixed –  unilateral 0
D1999 Prescription fluoride toothpaste 0
D1999 Chlorhexidine 0
D1999 PPE 0
D4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation 0
D4910 Periodontal maintenance, once ever 3 months following active periodontal treatment  0

* For example, if you have an examination and cleaning on July 15, 2023 you may not have another covered examination or cleaning until January 15, 2024.