Download BlueDental Care PS220

ADA Code
Diagnostic
BlueDental Care PS220
9310
9430
9440
9999
9999
120
140/150/160
180
210
220
230
270
272
274
330
460
470
Preventative
1110/1120
1110/1120
1201
1203
1330
1351
1510
1515
1520
1525
1550
Restorative
2140
2150
2160
2161
2940
2999
Resin Restoration
2330
2331
2332
2391
2392
2393
2394
2510
2520
2530
Crown & Bridge
2740
2750
2751
2752
2790
Consultation
Office Visit Normal hours
Office Visit after hours
Emergency visit
Broken appointments
Procedure
Periodic oral evalution
Limited/Comprehensive oral eval
Comprehensive periodontal evaluation
X-Ray Intraoral
X-Ray Intraoral Periapical first film
X-Ray Intraoral Periapical each add
X-Ray Bitewing - Single film
X-Ray Bitewings two films
Bitewings four films
Panoramic Film
Pulp vitality tests
Diagnostic Casts
Prophylaxix adult/child routine
Prophylaxix adult/child additional
Topical application of fluoride 16 yr
Topical app of fluoride 16yr not including prophylaxis
Oral Hygiene instruction
Sealant per tooth
Space Maintainer fixed unilateral
Space Maintainer fixed bilateral
Space Maintainer removable unilateral
Space Maintainer removable bilateral
Recementation of Space Maintainer
Amalgam one surface permanent
Amalgam two surfaces permanent
Amalgam three surface permanent
Amalgam four or more surfaces permanent
Sedative filling
Sedative base under fillings by report
Resin one surface anterior
Resin two surfaces anterior
Resin three surfaces anterior
Resin-based composite - one surface, posterior
Resin-based composite - two surface, posterior
Resin-based composite - three surface, posterior
Resin-based composite - 4+ surface, posterior
Inlay metallic one surface
Inlay metallic two surface
Inlay metallic three or more surfaces
Crown porcelain/ceramic substrate
Crown porcelain fused to high noble metal
Crown porcelain fused to predominantly base metal
Crown porcelain fused to noble metal
Crown full cast high noble metal
Patient Pays
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
15.00
5.00
35.00
20.00
10.00
No Charge
No Charge
10.00
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
20.00
No Charge
No Charge
No Charge
10.00
$45 + Lab
$45 + Lab
$85 + Lab
$85 + Lab
10.00
No Charge
No Charge
No Charge
No Charge
15.00
No Charge
35.00
40.00
50.00
60.00
80.00
100.00
120.00
95.00
105.00
130.00
$280 + Lab
$280 + Lab
280.00
$280 + Lab
$280 + Lab
Endodontics
Periodontics
Prosthodontics
2791
2792
2910
2920
2930
2950
2951
2952
2953
2954
2962
Crown full cast predominantly base netal
Crown full cast noble metal
Recement Inlay
Recement crown
Prefabricated stainless stell crown primary tooth
Core buildup including any pins
Pin retention per tooth
Cast post and core in addtion to crown
Each additional cast post same tooth
Prefabriated post and core in addtion to crwon
Labial veneer porcelain laminate laboratory
3220
3221
3310
3320
3330
3410
Therapeutic pulpotomy
Gross pulpal debridement primary and perm tooth
Root canal therapy anterior excluding final restoration
Root canal therapy bicuspid excluding final restoration
Root canal therapy molar excluding final restoration
Apicoectomy/periradicular surgery anterior
$
$
$
$
$
$
35.00
100.00
100.00
200.00
250.00
125.00
4210
4211
4260
4261
4271
4341
4342
4355
4381
4910
Gingivectomy/gingivoplasty per quadrant
Gingivectomy/gingivoplasty per tooth
Osseous surgery - 4+ teeth per quad
Osseous surgery - 1-3 teeth per quad
Free soft tissue graft procedure inc.donor site surgery
Periodontal scaling and root planning - 4+ teeth per quad
Periodontal scaling and root planning - 1-3 teeth per quad
Full mouth debridement
localized delivery of chemotherapeutic agents per tooth
Periodontal maintenance procedures following active ther
$
$
$
$
$
$
$
$
$
$
125.00
40.00
350.00
350.00
225.00
50.00
50.00
45.00
45.00
50.00
5110
5120
5130
5140
5211
5212
5213
5214
5410
5411
5421
5422
Repairs to Prosthetics
5510
5520
5610
5630
5640
5650
5730
5731
5740
5741
5750
5751
5760
Complete denture maxillary
Complete denture mandibular
Immediate denture maxillary
Immediate denture mandibular
Maxillary partial denture resin base
Mandibular partial denture resin base
Maxillary partial denture cast metal framework resin base
Mandibular partial denture cast metal framework
Adjust complete denture maxillary
Adjust complete denture mandibular
Adjust partial denture maxillary
Adjust partial denture mandibular
Repair broken complete denture base
Replace missing or broken teeth complete denture
Repair resin denture base
Repair or replace broken clasp
Replace broken teeth per tooth
Add tooth to existing partial denture
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
Reline maxillary partial denture (laboratory)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
280.00
$280 + Lab
15.00
15.00
75.00
45.00
15.00
$90 + Lab
$90 + Lab
90.00
$280 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
$300 + Lab
15.00
15.00
15.00
15.00
$15 + Lab
$15 + Lab
$15 + Lab
$15 + Lab
$15 + Lab
$30 + Lab
50.00
50.00
50.00
50.00
$35 + Lab
$35 + Lab
$35 + Lab
5761
5850
5851
Prosthodontics Fixed
6210*
6211
6212*
6240*
6241
6242*
6750*
6751
6752*
6790*
6791
6792*
6930
Reline mandibular partial denture (laboratory)
Tissue conditioning maxillary
Tissue conditioning mandibular
$
$
Pontic cast high noble metal
Pontic cast predominantly base metal
Pontic cast noble metal
Pontic porcelain fused to high noble metal
Pontic porcelain fused to predominantly base metal
Pontic porcelain fused to noble metal
Crown porcelain fused to high noble metal
Crown porcelain fused to predominantly base metal
Crown porcelain fused to noble metal
Crown full cast high noble metal
Crown full cast predominantly base metal
Crown full cast noble metal
Recement fixed partial denture (per unit)
$
$
$
$
$
$
$
$
$
$
$
$
$
Extractions/oral and maxillofacial Surgery
7111
7140
7210
7220
7230
7240
7250
7310
7320
7510
Coronal remnants, deciduous tooth
Extraction, erupted tooth, or exposed roots
Surgical removal of erupted tooth
Removal of impacted tooth soft tissue
Removal of impacted tooth partially bony
Removal of impacted tooth completely bony
Surgical removal of residual tooth roots
Alveoloplasty in conjunction with extractions per quadrant
Alveoloplasty not in conjunction with extractions per quadrant
Incision and drainage of abscess intraoral
Orthodontics
8070/8080 Comprehensive orthodontic treatment of the transitional/
adolescent dentition. Children up to 19 yrs of age up to
24 months of routine (full banded) orthodontic treatment
for Class I and Class II cases
Consultation
Evaluation
Records/ Treatment Planning
Orthodontic Treatment
8090 Comprehensive orthodontic treatment of the adult dentition
Adult 19 years of age and over up to 24 months of
routine (full banded) orthodontic treatment for Class I and
Class II cases
Consultation
Evaluation
Records/ Treatment Planning
Orthodontic Treatment
8680 Retension
Adjunctive General Services
9215 Local anesthesia
9230 Analgesia (nitrous oxide per 15 minutes)
9450 Case presentation, detailed and extensive treatment planning
9951 Occlusal adjustment limited
9952 Occlusal adjustment complete
$35 + Lab
30.00
30.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
280.00
10.00
$
$
$
$
$
$
$
$
No Charge
No Charge
40.00
50.00
70.00
85.00
35.00
35.00
70.00
25.00
$
$
$
No Charge
35.00
250.00
1,800.00
$
$
$
$
No Charge
35.00
250.00
2,000.00
450.00
$
$
$
No Charge
15.00
No Charge
25.00
150.00
* The above copayments do not include the additional cost of precious (high noble) and semi precious (noble) m
The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi precious metal
This is only a summary of the benefits please refer to your Summary Plan Description for actual benefits,
conditions, limitations, exclusion and contingencies.
metal.