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/Counseling with primary caregiver for patients up to age 3 - includes caries susceptibility test D0425 and oral hygiene instruction D1330. Limit 2 during calendar year for any combination of oral evaluations

D0150 Comprehensive oral evaluation - 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 - complete 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

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 ofbitewings 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

D0425 Caries susceptibility tests

D0486 Accession of brush biopsy