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The document provides a code-to-description mapping for services such as periodic and comprehensive oral evaluations, radiographic imaging (intraoral films, bitewings, panoramic and cephalometric), cone beam CT and other advanced imaging, and selected medical diagnostic tests. Each entry pairs a specific service code with a fee, including cases where the reimbursed amount is $0.00.",{"@graph":63,"@context":117},[64,80,100],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":21,"@type":70,"position":76},"https://docshare.wps.com/template/invoices/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medicaid-fee-schedule-2025-tn-child-dental-procedure-fees/573949/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":94,"encodingFormat":93,"isAccessibleForFree":95,"interactionStatistic":96},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medicaid-fee-schedule-2025-tn-child-dental-procedure-fees/573949.png","ImageObject",442,249,{"name":88,"@type":89},"Jake","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-14",true,{"@type":97,"interactionType":98,"userInteractionCount":9},"InteractionCounter",{"@type":99},"ViewAction",{"@type":101,"mainEntity":102},"FAQPage",[103,109,113],{"name":104,"@type":105,"acceptedAnswer":106},"What information does the fee schedule provide for each entry?","Question",{"text":107,"@type":108},"Each row lists a procedure code, its description, and the associated fee amount for Medicaid reimbursement.","Answer",{"name":110,"@type":105,"acceptedAnswer":111},"How are dental evaluation services reflected in the schedule?",{"text":112,"@type":108},"The schedule includes multiple oral evaluation types (periodic, limited, comprehensive) and re-evaluation services, each with an indicated fee.",{"name":114,"@type":105,"acceptedAnswer":115},"Are there procedures in the schedule with $0.00 fees?",{"text":116,"@type":108},"Yes. Some listed diagnostic or imaging services show a reimbursement fee of $0.00 in the schedule table.","https://schema.org",{"og:url":78,"og:type":119,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":121,"canonical":78},"index,follow",{"doc_id":123,"site_id":56},573949,1792002366,{"code":4,"msg":5,"data":126},{"doc_id":123,"user_id":127,"nickname":88,"user_avatar":128,"doc_module":9,"category_id":20,"category_name":21,"doc_title":59,"doc_description":61,"doc_content":129,"file_id":130,"file_url":131,"file_type":132,"file_size":133,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":134,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":140},962084928904,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","| CODE | DESCRIPTION | FEE |\n| --- | --- | --- |\n| D0120 | periodic oral evaluation | $29.24 |\n| D0140 | limited oral evaluation | $27.33 |\n| D0145 | oral evaluation for a patient under 3 years of age | $29.24 |\n| D0150 | comprehensive oral evaluation | $34.40 |\n| D0160 | detailed & extensive oral evaluation-problem focused, by report | $46.96 |\n| D0170 | re-evaluation | $27.33 |\n| D0171 | re-evaluation--post op | $27.33 |\n| D0180 | comprehensive periodontal evaluation | $0.00 |\n| D0190 | screening of a patient-FOR MEDICAL PROVIDER USE ONLY IN NTFV PROGRAM | $12.00 |\n| D0191 | assessment of a patient | $0.00 |\n| D0210 | intraoral-comprehensive series of radiographic images | $69.37 |\n| D0220 | intraoral-periapical 1st film | $13.96 |\n| D0230 | intraoral-periapical each additional | $10.74 |\n| D0240 | intraoral-occlusal film | $13.82 |\n| D0250 | extraoral-1st film | $16.39 |\n| D0251 | extraoral posterior dental radiographic image | $16.39 |\n| D0270 | bitewing-single film | $12.88 |\n| D0272 | bitewing-two films | $20.77 |\n| D0273 | bitewing-three films | $26.23 |\n| D0274 | bitewing-four films | $31.70 |\n| D0277 | vertical bitewings-7 to 8 films | $44.12 |\n| D0310 | sialography | $32.76 |\n| D0320 | tmj arthrogram | $382.17 |\n| D0321 | other tmj films-by report | $97.18 |\n| D0322 | tomographic survey | $382.17 |\n| D0330 | panoramic film | $56.30 |\n| D0340 | cephalometric film | $63.75 |\n| D0350 | oral/facial photographic image | $10.63 |\n| D0364 | cone beam CT capture and interpretation with limited field of view – less than one whole jaw | $0.00 |\n| D0365 | cone beam CT capture and interpretation with field of view of one full dental arch – mandible | $0.00 |\n| D0366 | cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without | $0.00 |\n| D0367 | cone beam CT capture and interpretation with field of view of both jaws, with or without cranium | $81.15 |\n| D0368 | cone beam CT capture and interpretation for TMJ series including two or more exposures | $0.00 |\n| D0369 | maxillofacial MRI capture and interpretation | $0.00 |\n| D0370 | maxillofacial ultrasound capture and interpretation | $0.00 |\n| D0371 | sialoendoscopy capture and interpretation | $0.00 |\n| D0372 | intraoral tomosynthesis-comprehensive series of radiographic images | $71.28 |\n| D0373 | intraoral tomosynthesis-bitewing radiographic image | $13.24 |\n\n\n| D0374 | intraoral tomosynthesis-periapical radiographic image | $14.35 |\n| --- | --- | --- |\n| D0380 | cone beam CT image capture with limited field of view – less than one whole jaw | $0.00 |\n| D0381 | cone beam CT image capture with field of view of one full dental arch – mandible | $0.00 |\n| D0382 | cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium | $0.00 |\n| D0383 | cone beam CT image capture with field of view of both jaws, with or without cranium | $0.00 |\n| D0384 | cone beam CT image capture for TMJ series including two or more exposures | $0.00 |\n| D0385 | maxillofacial MRI image capture | $0.00 |\n| D0386 | maxillofacial ultrasound image capture | $0.00 |\n| D0387 | intraoral tomosynthesis – comprehensive series of radiographic images – image capture only | $0.00 |\n| D0388 | intraoral tomosynthesis – bitewing radiographic image – image capture only | $0.00 |\n| D0389 | intraoral tomosynthesis – periapical radiographic image – image capture only | $0.00 |\n| D0393 | virtual treatment simulation using 3D image volume or surface scan | $0.00 |\n| D0394 | digital subtraction of two or more image volumes of the same modality | $0.00 |\n| D0395 | fusion of two or more 3D image volumes of one or more modalities | $0.00 |\n| D0411 | HbA1c in-office point of service testing | $0.00 |\n| D0412 | blood glucose level test- in-office using a glucose meter | $0.00 |\n| D0414 | laboratory processing of microbial specimen to include culture and sensitivity studie | $0.00 |\n| D0415 | bacteriologic studies | $10.92 |\n| D0416 | vira","cbCairVQ2Pgsyl4f","https://ap.wps.com/l/cbCairVQ2Pgsyl4f","pdf",395876,38,"English","# Procedure Code Fee List\n## Oral Evaluation and Re-evaluation\n## Diagnostic Radiology and Imaging\n## Laboratory and Medical Diagnostic Tests","[{\"question\":\"What information does the fee schedule provide for each entry?\",\"answer\":\"Each row lists a procedure code, its description, and the associated fee amount for Medicaid reimbursement.\"},{\"question\":\"How are dental evaluation services reflected in the schedule?\",\"answer\":\"The schedule includes multiple oral evaluation types (periodic, limited, comprehensive) and re-evaluation services, each with an indicated fee.\"},{\"question\":\"Are there procedures in the schedule with $0.00 fees?\",\"answer\":\"Yes. Some listed diagnostic or imaging services show a reimbursement fee of $0.00 in the schedule table.\"}]","Medicaid Fee Schedule 2025 TN Child - Dental Procedure Fees | PDF",1791955135,13]