WebGUARDIAN ®DENTAL COVERAGE FOR INDIVIDUALS AND FAMILIES ON THE HEALTH INSURANCE EXCHANGE FOR NEW YORK Schedule of Benefits CDT Codes Plan Schedules - Copayments D0100-D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation -established patient $0 D0140 Limited oral evaluation -problem focused 0 Webdentalexchange.guardiandirect.com
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