Page 2 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D0230 Intraoral – periapical each additional radiographic image $0 D0240 Intraoral – occlusal radiographic image $0 D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector $0 D0251 Extra-oral posterior dental radiographic image $0 D0270 Bitewing – single radiographic image $0 D0272 Bitewings – two radiographic images $0 D0273 Bitewings – three radiographic images $0 D0274 Bitewings – four radiographic images $0 D0277 Vertical bitewings – 7 to 8 radiographic images $0 D0330 Panoramic radiographic image $0 D0340 2D cephalometric radiographic image – acquisition, measurement and analysis $0 D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $0 D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw $180 D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible $180 D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium $180 D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium $180 D0372 A radiographic survey of the whole mouth intended to display the crowns and roots of all teeth, periapical areas, interproximal areas and alveolar bone including edentulous areas. Comprehensive series of radiographic images. $0 D0373 Intraoral tomosynthesis- bitewing radiographic image $0 D0374 Intraoral tomosynthesis – periapical radiographic image $0 D0380 Cone beam CT image capture with limited field of view – less than one whole jaw $180 D0381 Cone beam CT image capture with field of view of one full dental arch – mandible $180 D0382 Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium $180 D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium $180 D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report $0 D0396 3D printing of a 3D dental surface scan $0 Tests and Examinations D0415 Collection of microorganisms for culture and sensitivity $0 D0425 Caries susceptibility tests $0 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $50