Download BlueDental Choice Copayment (PPO)

BlueDental Choice Copayment (PPO)
2014 Schedule of Allowances – Statewide
For General Dentists and Specialists
Note: Please refer to the 2014 CDT Guide for general policy coverage guidelines, limitations and exclusions. For detailed benefit information, please visit the website at
www.FloridaBlueDental.com or call (866) 445-5148.
CDT
CODE
DESCRIPTION
MEMBER
MAXIMUM
MAXIMUM
COPAYMENT
ALLOWANCE
ALLOWANCE
SPECIALIST
GENERAL DENTIST
D0210
CLINICAL ORAL EVALUATIONS
Periodic oral evaluation
Limited oral evaluation - problem focused
Oral evaluation for a patient under three years of age and counseling with primary caregiver
Comprehensive oral evaluation - new or established patient
Comprehensive periodontal evaluation - new or established patient
IAGNOSTIC IMAGING
Intraoral - complete series of radiographic images
$17
$61
$64
D0220
Intraoral periapical - first radiographic image
$4
$14
$14
D0230
Intraoral periapical - each additional radiographic image
$2
$8
$11
D0240
Intraoral - occlusal radiographic image
$10
$22
$22
D0270
Bitewing - single radiographic image
$0
$15
$15
D0272
D0273
D0274
D0277
D0330
D0340
D0350
Bitewings - two radiographic images
Bitewings - three radiographic images
Bitewings - four radiographic images
Vertical bitewings - 7-8 radiographic images
Panoramic radiographic image
Cephalometric radiographic image
Oral/facial photographic image obtained intraorally or extraorally
TESTS AND EXAMINATIONS
Diagnostic casts
DENTAL PROPHYLAXIS
Prophylaxis - adult
Prophylaxis - child
TOPICAL FLUORIDE TREATMENT (Office Procedure)
Topical application of fluoride varnish
Topical application of fluoride
OTHER PREVENTIVE SERVICES
Sealant - per tooth
Preventive resin restoration - in a moderate to high caries risk patient - permanent tooth
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable - unilateral
Space maintainer - removable - bilateral
Re-cementation of space maintainer
Removal of fixed space maintainer
RESTORATIVE SERVICES
Amalgam - one surface, primary or permanent
Amalgam - two surfaces, primary or permanent
Amalgam - three surfaces, primary or permanent
Amalgam - four or more surfaces, primary or permanent
Resin-based composite - one surface, anterior
Resin-based composite - two surfaces, anterior
Resin-based composite - three surfaces, anterior
Resin-based composite - four or more surfaces or involving incisal angle (anterior)
Resin-based composite - one surface, posterior
Resin-based composite - two surfaces, posterior
Resin-based composite - three surfaces, posterior
Resin-based composite - four or more surfaces, posterior
Inlay - metallic - one surface
Inlay - metallic - two surfaces
Inlay - metallic - three or more surfaces
Onlay - metallic - two surfaces
Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Inlay - porcelain/ceramic - one surface
Inlay - porcelain/ceramic - two surfaces
Inlay - porcelain/ceramic - three or more surfaces
Onlay - porcelain/ceramic, two surface
Onlay - porcelain/ceramic - three surface
Onlay - porcelain/ceramic - four or more surfaces
Crown - resin-based composite (indirect)
Crown - porcelain/ceramic substrate
$0
$0
$0
$0
$14
$28
$13
$18
$23
$28
$30
$51
$57
$27
$19
$23
$28
$30
$53
$57
$27
$18
$37
$37
$0
$0
$43
$34
$46
$34
$0
$0
$19
$19
$19
$19
$6
$6
$47
$66
$53
$75
$0
$29
$23
$23
$166
$236
$188
$268
$37
$98
$23
$23
$166
$236
$188
$268
$37
$128
$15
$19
$23
$28
$20
$26
$30
$32
$22
$29
$37
$38
$221
$239
$257
$239
$297
$306
$222
$241
$261
$273
$312
$325
$148
$324
$54
$68
$84
$101
$72
$91
$107
$115
$79
$106
$129
$138
$395
$428
$460
$428
$531
$548
$397
$430
$466
$487
$558
$579
$264
$578
$55
$75
$88
$106
$72
$91
$107
$115
$79
$106
$129
$138
$395
$428
$460
$428
$531
$548
$397
$430
$466
$487
$558
$579
$264
$578
D0120
D0140
D0145
D0150
D0180
D0470
D1110
D1120
D1206
D1208
D1351
D1352
D1510
D1515
D1520
D1525
D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2710
D2740
$0
$0
$0
$0
$0
$22
$32
$31
$31
$64
$22
$34
$31
$33
$65
CDT
CODE
DESCRIPTION
MEMBER
COPAYMENT
MAXIMUM
MAXIMUM
ALLOWANCE
ALLOWANCE
SPECIALIST
GENERAL DENTIST
D2750
Crown - porcelain fused to high noble metal
$315
$564
$564
D2751
Crown - porcelain fused to predominantly base metal
$289
$517
$517
D2752
Crown - porcelain fused to noble metal
$302
$539
$539
D2780
Crown - 3/4 cast high noble metal
$284
$586
$586
D2781
Crown - 3/4 cast predominantly base metal
$228
$498
$498
D2783
Crown - 3/4 porcelain/ceramic
$257
$602
$602
D2790
Crown - full cast high noble metal
$301
$538
$538
D2791
Crown - full cast predominantly base metal
$268
$478
$478
D2792
Crown - full cast noble metal
$285
$510
$510
D2794
Crown - titanium
$284
$603
$603
D2910
Recement inlay, onlay, or partial coverage restoration
$11
$40
$40
D2920
Recement crown
$11
$39
$39
D2929
Prefabricated porcelain/ceramic crown - primary tooth
$39
$138
$138
D2930
Prefabricated stainless steel crown - primary tooth
$37
$131
$131
D2931
Prefabricated stainless steel crown - permanent tooth
$38
$130
$130
D2940
Protective restoration
$12
$42
$46
D2950
Core build-up, including any pins when required
$28
$101
$101
D2951
Pin retention - per tooth, in addition to restoration
D2952
Post and core in addition to crown, indirectly fabricated
D2954
D2980
$6
$24
$24
$113
$201
$201
Prefabricated post and core in addition to crown
$74
$132
$132
Crown repair necessitated by restorative material failure
$53
$94
$94
D2981
Inlay repair necessitated by restorative material failure
$50
$76
$76
D2982
Onlay repair necessitated by restorative material failure
$50
$76
$76
D2983
Veneer repair necessitated by restorative material failure
$50
$76
$76
D2990
Resin infiltration of incipient smooth surface lesions
$6
$23
$23
ENDODONTICS
D3110
Pulp cap - direct (excluding final restoration)
$20
$49
$49
D3220
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentincomental junction and application of medicament
$47
$85
$85
D3222
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
$47
$84
$84
D3230
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
$47
$84
$84
D3240
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
$47
$84
$84
D3310
Endodontic therapy, anterior tooth (excluding final restoration
$196
$351
$351
D3320
Endodontic therapy, bicuspid tooth (excluding final restoration
$231
$413
$413
D3330
Endodontic therapy, molar (excluding final restoration
$305
$544
$568
D3346
Retreatment or previous root canal therapy - anterior
$256
$458
$458
D3347
Retreatment or previous root canal therapy - bicuspid
$296
$529
$529
D3348
Retreatment or previous root canal therapy -molar
$358
$640
$640
D3351
Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)
$50
$76
$76
D3352
Apexification/recalcification - interim medication replacement
$50
$76
$76
$132
$200
$200
D3353
D3410
Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption,
etc.)
Apicoectomy - anterior
$188
$336
$375
D3421
Apicoectomy - bicuspid (first root)
$227
$406
$406
D3425
Apicoectomy - molar (first root)
$235
$419
$456
D3426
Apicoectomy (each additional root)
$84
$150
$150
D3430
Retrograde filling - per root
$46
$83
$108
D3450
Root amputation - per root
$120
$215
$215
D3920
Hemisection (including any root removal), not including root canal therapy
$105
$188
$188
PERIODONTICS
D4210
Gingivectomy or gingivoplasty, four or more contiguous teeth or tooth bounded spaces per quadrant
$142
$253
$268
D4211
Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
$47
$84
$86
D4212
Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
$12
$43
$43
D4240
Gingival flap procedure, include root planing - four or more contiguous teeth or tooth bounded spaces per quadrant
$158
$295
$322
D4241
Gingival flap procedure, include root planing - one to three contiguous teeth or tooth bounded spaces per quadrant
$150
$268
$295
D4249
Clinical crown lengthening - hard tissue
$212
$379
$408
D4260
Osseous surgery (including flap entry and closure) - four or morecontiguous teeth or tooth bounded spaces per quadrant
$322
$575
$617
D4261
Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
$277
$495
$589
D4263
Bone replacement graft - first site in quadrant
$120
$215
$215
D4264
Bone replacement graft - each additional site in quadrant
$77
$138
$268
D4270
Pedicle soft tissue graft procedure
$225
$402
$402
D4273
Subepithelial connective tissue graft procedures, per tooth
$280
$500
$583
D4275
Soft tissue allograft
$221
$394
$445
D4276
Combined connective tissue and double pedicle graft, per tooth
$265
$474
$556
D4277
Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft
$236
$422
$422
D4278
Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site
$45
$71
$71
D4341
Periodontal scaling and root planing -four or more teeth per quadrant
$61
$110
$119
D4342
Periodontal scaling and root planing - one to three teeth per quadrant
$46
$83
$91
CDT
CODE
DESCRIPTION
MEMBER
COPAYMENT
MAXIMUM
MAXIMUM
ALLOWANCE
ALLOWANCE
GENERAL DENTIST
SPECIALIST
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$34
$61
$75
D4910
Periodontal maintenance
$34
$61
$70
PROSTHODONTICS, REMOVABLE
D5110
Complete denture - maxillary
$382
$681
$681
D5120
Complete denture - mandibular
$382
$681
$681
D5130
Immediate denture - maxillary
$418
$747
$747
D5140
Immediate denture - mandibular
$418
$747
$747
D5211
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)
$296
$530
$530
D5212
Mandibular partial denture - resin base (inc. any conventional clasps, rests and teeth)
$303
$541
$541
D5213
Maxillary partial denture - cast metal framework with resin denture bases (including and conventional clasps, rests and teeth)
$420
$750
$750
D5214
Mandibular partial denture - cast metal framework with resin denture bases (including and conventional clasps, rests and teeth)
$420
$750
$750
D5225
Maxillary partial denture - flexible base (including any conventional clasps, rests and teeth)
$420
$750
$750
D5226
Mandibular partial denture - flexible base (including any conventional clasps, rests and teeth
$420
$750
$750
D5281
Removable unilateral partial denture - one piece cast metal (including clasps and teeth )
$264
$400
$400
D5410
Adjust complete denture - maxillary
$10
$36
$36
D5411
Adjust complete denture - mandibular
$10
$36
$36
D5421
Adjust partial denture - maxillary
$10
$36
$36
D5422
Adjust partial denture - mandibular
$9
$36
$36
D5510
Replace broken complete denture base
$23
$81
$81
D5520
Replace missing or broken teeth - complete denture (each tooth)
$20
$70
$70
D5610
Repair resin denture base
$21
$74
$74
D5620
Repair cast framework
$23
$83
$83
D5630
Repair or replace broken clasp
$20
$73
$73
D5640
Replace broken teeth - per tooth
$18
$66
$66
D5650
Add tooth to existing partial denture
$27
$96
$96
D5660
Add clasp to existing partial denture
$31
$113
$113
D5670
Replace all teeth and acrylic on cast metal framework (maxillary)
$75
$268
$268
D5671
Replace all teeth and acrylic on cast metal framework (mandibular)
$75
$268
$268
D5710
Rebase complete maxillary denture
$73
$261
$261
D5711
Rebase complete mandibular denture
$73
$261
$261
D5720
Rebase maxillary partial denture
$66
$238
$238
D5721
Rebase mandibular partial denture
$66
$238
$238
D5730
Reline complete maxillary denture (chairside)
$38
$137
$137
D5731
Reline complete mandibular denture (chairside)
$38
$137
$137
D5740
Reline maxillary partial denture (chairside)
$34
$123
$123
D5741
Reline mandibular partial denture (chairside)
$34
$123
$123
D5750
Reline complete maxillary denture (laboratory)
$59
$210
$210
D5751
Reline complete mandibular denture (laboratory)
$57
$204
$204
D5760
Reline maxillary partial denture (laboratory)
$53
$188
$188
D5761
Reline mandibular partial denture (laboratory)
$53
$188
$188
D5850
Tissue conditioning, maxillary
$18
$65
$65
D5851
Tissue conditioning, mandibular
$19
$67
$67
IMPLANT SERVICES
D6010
Surgical placement of implant body: endosteal implant
$512
$1,190
$1,190
D6053
Implant/abutment supported removable denture for completely edentulous arch
$378
$889
$889
D6054
Implant/abutment supported removable denture for partially edentulous arch
$378
$889
$889
D6055
Connecting bar - implant supported or abutment supported
$178
D6056
Prefabricated abutment - includes modification and placement
$112
$263
$263
D6058
Abutment supported porcelain/ ceramic crown
$294
$685
$685
D6059
Abutment supported porcelain fused to metal crown (high noble metal)
$290
$676
$676
D6060
Abutment supported porcelain fused to metal crown (predominantly base metal)
$274
$639
$639
D6061
Abutment supported porcelain fused to metal crown (noble metal)
$280
$653
$653
D6062
Abutment supported cast metal crown (high noble metal)
$279
$650
$650
D6063
Abutment supported cast metal crown (predominantly base metal)
$240
$558
$558
D6064
Abutment supported cast metal crown (noble metal)
$252
$591
$591
D6065
Implant supported porcelain/ceramic crown
$289
$674
$674
D6066
Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
$282
$657
$657
D6067
Implant supported metal crown (titanium, titanium alloy, high noble metal)
$274
$638
$638
D6068
Abutment supported retainer for porcelain/ ceramic FPD
$294
$685
$685
D6069
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
$290
$676
$676
D6070
Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
$274
$639
$639
D6071
Abutment supported retainer for porcelain fused to metal FPD (noble metal)
$280
$653
$653
D6072
Abutment supported retainer for cast metal FPD (high noble metal)
$286
$659
$659
D6073
Abutment supported retainer for cast metal FPD (predominantly base metal)
$259
$602
$602
D6074
Abutment supported retainer for cast metal FPD (noble metal)
$279
$650
$650
D6075
Implant supported retainer for ceramic FPD
$289
$674
$674
CDT
CODE
DESCRIPTION
MEMBER
COPAYMENT
MAXIMUM
MAXIMUM
ALLOWANCE
ALLOWANCE
SPECIALIST
GENERAL DENTIST
D6076
Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)
$282
$657
$657
D6077
Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
$271
$637
$637
D6080
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments
$24
$56
$56
D6090
Repair implant supported prosthesis, by report
$83
$202
$202
D6095
Repair implant abutment, by report
$65
$152
$152
D6100
Implant removal, by report
$120
$283
$283
D6101
Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure
$160
$280
$280
D6102
Debridement and osseous contouring of periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure
$228
$400
$400
D6103
Bone graft for repair of periimplant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic
materials to aid in osseous regeneration
$114
$200
$200
D6104
Bone graft at time of implant placement
$114
$200
$200
D6190
Radiographic/surgical implant index, by report
$171
$300
$300
PROSTHODONTICS, FIXED
D6210
Pontic - cast high noble metal
$306
$547
$547
D6211
Pontic - cast predominantly base metal
$263
$469
$469
D6212
Pontic - cast noble metal
$274
$559
$559
D6214
Pontic - titanium
$283
$578
$578
D6240
Pontic - porcelain fused to high noble metal
$316
$565
$565
D6241
Pontic - porcelain fused to predominantly base metal
$288
$516
$516
D6242
Pontic - porcelain fused to noble metal
$302
$540
$540
D6245
Pontic - porcelain/ceramic
$299
$534
$534
D6545
Retainer - cast metal for resin bonded fixed prosthesis
$123
$220
$220
D6548
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
$115
$234
$234
D6600
Inlay porcelain/ceramic, two surfaces
$241
$430
$430
D6601
Inlay porcelain/ceramic, three or more surfaces
$251
$466
$466
D6604
Inlay - cast predominantly base metal, two surfaces
$239
$442
$442
D6605
Inlay - cast predominantly base metal, three or more surfaces
$257
$466
$466
D6606
Inlay - cast noble metal, two surfaces
$239
$428
$428
D6607
Inlay - cast noble metal, three or more surfaces
$257
$460
$460
D6608
Onlay - porcelain/ceramic, two surfaces
$273
$487
$487
D6609
Onlay - porcelain/ceramic, three or more surfaces
$312
$558
$558
D6612
Onlay - cast predominantly base metal, two surfaces
$241
$484
$484
D6613
Onlay - cast predominantly base metal, three or more surfaces
$248
$506
$506
D6615
Onlay - cast noble metal, three or more surfaces
$297
$531
$531
D6720
Crown - resin with high noble metal
$299
$534
$534
D6721
Crown - resin with predominantly base metal
$250
$447
$447
D6722
Crown - resin with noble metal
$277
$495
$495
D6740
Crown - porcelain/ceramic
$350
$626
$626
D6750
Crown - porcelain fused to high noble metal
$315
$564
$564
D6751
Crown - porcelain fused to predominantly base metal
$288
$515
$515
D6752
Crown - porcelain fused to noble metal
$302
$539
$539
D6780
Crown - 3/4 cast high noble metal
$267
$545
$545
D6781
Crown - 3/4 cast predominantly base metal
$200
$500
$500
D6782
Crown - 3/4 cast noble metal
$225
$506
$506
D6783
Crown - 3/4 porcelain/ceramic
$267
$561
$561
D6790
Crown - full cast high noble metal
$301
$538
$538
D6791
Crown - full cast predominantly base metal
$266
$475
$475
D6792
Crown - full cast noble metal
$280
$500
$500
D6930
Recement fixed partial denture
$17
$59
$59
D6980
Fixed partial denture repair, necessitated by restorative material failure
$30
$108
$108
$60
ORAL AND MAXILLOFACIAL SURGERY
D7111
Extraction, corneal remnants - deciduous tooth
$11
$39
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
$17
$59
$65
$31
$112
$119
D7210
D7220
Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated
Removal of impacted tooth - soft tissue
$39
$142
$159
D7230
Removal of impacted tooth - partially bony
$53
$189
$201
D7240
Removal of impacted tooth - completely bony
$64
$230
$240
D7241
Removal of impacted tooth - completely bony, with unusual surgical complications
$72
$257
$268
D7250
Surgical removal of residual roots (cutting procedure)
$32
$115
$129
D7251
Coronectomy
$64
$230
$230
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
$58
$243
$243
D7280
Surgical access of an unerupted tooth
$73
$262
$279
D7282
Mobilization of erupted or malpositioned tooth to aid eruption
$45
$162
$189
D7283
Placement of device to facilitate eruption of impacted tooth
$27
$77
$99
D7310
Alveoloplasty, in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
$31
$111
$111
D7311
Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
$31
$111
$111
CDT
CODE
DESCRIPTION
MEMBER
COPAYMENT
MAXIMUM
MAXIMUM
ALLOWANCE
ALLOWANCE
SPECIALIST
GENERAL DENTIST
D7320
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
$42
$149
$182
D7321
Alveoloplasty, not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
$42
$149
$182
D7471
Removal of lateral exostosis (maxilla or mandible)
$243
$647
$647
D7510
Incision and drainage of abscess - intraoral soft tissue
$21
$76
$103
D7910
Suture of recent small wounds up to 5 cm
$69
$286
$305
D7921
Collection and application of autologous blood concentrate product
$40
IC
IC
D7971
Excision of pericoronal gingiva
$31
$130
$130
D7960
Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure
D7963
Frenuloplasty
$98
$176
$215
$112
$190
$200
ORTHODONTICS - Payment for the following orthodontic services is limited to the Orthodontic Lifetime Maximum specific to the
Member's Benefit Plan.
D8010
Limited orthodontic treatment of the primary dentition
*
$2,600
$2,600
D8020
Limited orthodontic treatment of the transitional dentition
*
$3,000
$3,000
D8030
Limited orthodontic treatment of the adolescent dentition
*
$3,500
$3,500
D8040
Limited orthodontic treatment of the adult dentition
*
$3,800
$3,800
D8050
Interceptive orthodontic treatment of the primary dentition
*
$3,000
$3,000
D8060
Interceptive orthodontic treatment of the transitional dentition
*
$3,200
$3,200
D8070
Comprehensive orthodontic treatment of the transitional dentition
*
$5,500
$5,500
D8080
Comprehensive orthodontic treatment of the adolescent dentition
*
$5,700
$5,700
D8090
Comprehensive orthodontic treatment of the adolescent dentition
*
$5,700
$5,700
D8210
Removable appliance therapy
*
$1,000
$1,000
D8220
Fixed appliance therapy
*
$1,200
$1,200
D8660
Pre-orthodontic treatment visit
*
$500
$500
D8670
Periodic orthodontic treatment visit (as part of contract)
*
$350
$350
D8680
Orthodontic retention (removal of appliances, construction and placement of retainer(s))
*
$600
$600
D8690
Orthodontic treatment (alternative billing to a contract fee)
*
$300
$300
D8691
Repair of orthodontic appliance
*
$250
$250
D8694
Repair of fixed retainers, includes reattachment
*
$400
$400
$12
$44
$44
$182
ADJUNCTIVE GENERAL SERVICES
D9110
Palliative (emergency) treatment. of dental pain, minor procedure
ANESTHESIA
D9220
Deep sedation/general anesthesia - first 30 minutes
$50
$178
D9221
Deep sedation/general anesthesia - each additional 15 minutes
$19
$68
$75
D9241
Intravenous sedation - first 30 min. (medically necessary only)
$44
$157
$182
D9242
Intravenous sedation – each additional 15 min (medically necessary only)
$11
$40
$70
$0
$54
$54
$0
$29
$33
$11
$40
$40
$8
$30
$35
$52
$215
$215
PROFESSIONAL CONSULTATION
D9310
Consultation - diagnostic service performed by dentist or physician other than requesting dentist or physician
PROFESSIONAL VISITS
D9430
Office visit for observation (during regularly scheduled hours) - no other services performed
MISCELLANEOUS SERVICES
D9610
Therapeutic parenteral drug, single administration
D9930
Treatment of complications (post-surgical) - unusual circumstances, by report
D9940
Occlusal guard, by report
* No fixed Member Copayment. Member Responsibility is equal to Maximum Allowance less FCL payment.
Disclaimer:
Some codes may be listed that are not covered under a particular member’s benefit plan. Verification of benefits is recommended to ensure coverage.
You may bill your usual and customary charge for any service not covered by the member’s plan; you will not be held to the scheduled allowance for that service.