GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 2 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment 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 D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $0 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 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 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 D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written 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) $20 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) $15 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 D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1510 Space maintainer – fixed, unilateral – per quadrant Excludes a distal shoe space maintainer $0