Page 3 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 D0472 Accession of tissue, gross examination, preparation and transmission of written report $0 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $0 D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $0 D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report $0 D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report $0 D0502 Other oral pathology procedures, by report $0 Preventive Services D1110 Removal of plaque, calculus and stains from the tooth structures and implants in the permanent and transitional dentition. It is intended to control local irritational factors. $0 • Additional-adult prophylaxis (maximum of 2 additional per year) $35 D1120 Removal of plaque, calculus and stains from the tooth structures and implants in the primary and transitional dentition. It is intended to control local irritational factors. $0 • Additional-child prophylaxis (maximum of 2 additional per year) $25 D1206 Topical application of fluoride varnish $0 D1208 Topical application of fluoride – excluding varnish $0 D1310 Nutritional counseling for control of dental disease $0 D1320 Tobacco counseling for the control and prevention of oral disease $0 D1330 Oral hygiene instructions $0 • Includes periodontal hygiene instruction D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1353 Sealant repair - per tooth $0 D1354 Application of caries arresting medicament – per tooth. Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. $0 D1355 Caries preventive medicament application – per tooth $0 D1510 Space maintainer – fixed, unilateral – per quadrant Excludes a distal shoe space maintainer $25 D1516 Space maintainer – fixed – bilateral, maxillary $25 D1517 Space maintainer – fixed – bilateral, mandibular $25 D1520 Space maintainer – removable, unilateral – per quadrant $35 D1526 Space maintainer – removable – bilateral, maxillary $35 D1527 Space maintainer – removable – bilateral, mandibular $35