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APPENDIX B <br />CODE ON DENTAL PROCEDURES AND NOMENCLATURE <br />NOTE: All the listed procedures may not be benefits under the terms of your contract, Refer to your <br />contract for your specific benefits. <br />00100 - D0999 DIAGNOSTIC <br />Clinical oral evaluations <br />D0120 Periodic oral evaluation - established patient <br />D0140 Limited oral evaluation - problem focused <br />DO 145 Oral evaluation for a patient under three years of age and counseling with primary <br />caregiver <br />D0150 Comprehensive oral evaluation - new or established patient <br />DO 160 Detailed and extensive oral evaluation - problem focused; by report <br />D0170 Re-evaluatlon - limited, problem focused (established patient; not post-operative <br />visit) <br />D0180 Comprehensive periodontal evaluation - new or established patient <br />D0190 Screening of a patient <br />D0191 Assessment of a patient <br />Radiographs/diagnostic imaging (Including Interpretation) <br />00210 Intraoral - complete series of radiographic Images <br />00220 Intraoral - perlapical first radiographic Image <br />D0230 Intraoral - periapical each additional radiographic Image <br />D0240 Intraoral - occlusal radiographic Image <br />D02.50 Extra -oral - 2D projection radiographic image created using a stationary radiation <br />source, and detector <br />D0251 Extra -oral posterior dental radiographic image <br />00270 Bitewing - single radiographic Image. . <br />D0272 Bitewings - two radiographic Images <br />D0273 Bitewings - three radiographic images <br />D0274 Bitewings - four radiographic Images <br />D0277 Vertical bitewings - 7 to 8 radiographic Images <br />D0310 Sialography <br />D0320 Temporomandibular joint arthrogram, Including Injection <br />D0321 Other temporomandibular joint radiographic images, by report <br />D0322 Tomographic survey <br />D0330 Panoramic radiographic image <br />D0340 2D cephalometric radiographic Image - acquisition, measurement and analysis <br />D0350 Oral/facial photographic Images obtained Intraorally or extraorally <br />Tests and examinations <br />D0411 HbAlc In-offlce point of service testing <br />D0415 Collection of microorganisms for culture and sensitivity <br />D0416 Viral culture <br />D0422 Collection and preparation of genetic sample material for laboratory analysis and <br />report <br />D0423 Genetic test for susceptibility to diseases - specimen analysis <br />D0425 Caries susceptibility tests <br />D0431 Adjunctive pre -diagnostic test that aids in detection of mucosal abnormalities Including <br />premalignant and malignant lesions, not to include cytology or biopsy procedures <br />D0460 Pulp vitality tests <br />D0470 Diagnostic casts <br />CDT2018(Eff. 01-01=18) <br />25C-76 <br />