Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic

D0120 Periodic oral evaluation - Limit 2 during the calendar year for any combination of oral evaluations

D0140 Limited oral evaluation - problem focused - Limit 2 during the calendar year for any combination of oral evaluations

D0145 Oral evaluation for a patient under 3 years of age and counseling with a primary caregiver. Limit 2 during calendar year for any combination of oral evaluations

D0150 Comprehensive oral evaluation - new or established patient - Limit 2 during the calendar year for any combination of oral evaluations

D0180 Comprehensive periodontal evaluation - Limit 2 during the calendar year for any combination of oral evaluations. If billed with a D4910, the D0180 will alternate to a D0120.

D0210 Intraoral - comprehensive series of radiographic images including bitewings - Limit 1 every 60 months

D0220 Intraoral - periapical radiographic image

D0230 Intraoral - periapical each additional radiographic image

D0240 Intraoral - occlusal radiographic image

D0250 Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector

D0251 Extraoral posterior dental radiographic image

D0270 Bitewing - single radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others

D0272 Bitewings - two radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0273 Bitewings - three radiographic images Limit - 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0274 Bitewings - four radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0277 Bitewings - Seven to eight radiographic images - Limit 2 per calendar year for any combination of bitewings for patients up to age 22, 1 per calendar year for any combination of bitewings for all others.

D0330 Panoramic radiographic image - Limit 1 every 60 months

D0372 Intraoral tomosynthesis – comprehensive series of radiographic images - Limit 1 every 60 months

D0373 Intraoral tomosynthesis – bitewing radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others

D0374 Intraoral tomosynthesis – periapical radiographic image

D0425 Caries susceptibility tests

D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report