Voluntary HMO and PPO Dental

2026-11-03

D0120 Periodic oral evaluation ( 2 every 12 months ) $ 0 D0120 Periodic oral evaluation ( additional ) $ 15 D0140 Limited oral evaluation ( problem focused ) ( 2 every 12 months ) $ 15 D0145 Oral exam for patient under 3 years of age ( 2 every 12 months ) $ 0 D0145 Oral exam for patient under 3 years of age ( additional ) $ 19 D0150 Comprehensive oral exam ( 2 every 12 months ) $ 0 D0150 Comprehensive oral exam ( additional ) $ 21 D0160 Detailed oral evaluation - problem focused report ( 2 every 12 months ) $ 0 D0170 Re - evaluation - limited problem focused ( 2 every 12 months ) $ 0 D0180 Comprehensive periodontal evaluation ( 2 every 12 months ) $ 0 D0210 Intraoral - complete including bitewing x - ray ( 1 every 5 year period ) $ 5 D0210 Intraoral - complete including bitewing x - ray ( additional ) $ 48 D0220 Single periapical x - ray $ 0 D0230 Periapical x - ray : each additional x - ray $ 0 D0240 Intraoral - occlusal film $ 10 D0270 Bitewing x - ray : single ( 2 every 12 months ) $ 0 D0272 Bitewing x - ray : 2 films ( 2 every 12 months ) $ 0 D0272 Bitewing x - rays 2 films ( additional ) $ 12 D0273 Bitewing x - rays 3 films ( 2 every 12 months ) $ 0 D0273 Bitewing x - rays 3 films ( additional ) $ 18 D0274 Bitewing x - rays 4 films ( 2 every 12 months ) $ 0 D0274 Bitewing x - rays 4 films ( additional ) $ 21 D0277 Vertical bitewing x - rays ( 2 every 12 months ) $ 0 D0277 Vertical bitewing x - rays ( additional ) $ 21 D0330 Panoramic film incl . bitewing x - rays ( 1 every 5 year period ) $ 5 D0330 Panoramic film incl . bitewing x - rays ( additional ) $ 42 D0431 Adjunctive pre - diagnostic test that aids in detection of mucosal abnormalities $ 0 D0460 Pulp vitality tests $ 0 D0470 Diagnostic casts $ 0 D1110 Prophylaxis adult ( 2 every 12 months ) $ 0

Arizona

2026-03-27