Download DentalPlus - Blue Cross Blue Shield of Arizona

Patient Fees
DentalPlus
ADA
Code
Description of Services
fee
ADA
Code
Description of Services
An easy-to-use dental plan.
Plan 2
www.azblue.com
fee
DentalPlus
DentalPlus gives you
a lot of reasons to smile.
DentalPlus covers many
basic dental needs.
A dental plan that offers affordability and convenience
will keep you and your family smiling.
The DentalPlus benefit plan includes the following:
That’s why Blue Cross Blue Shield of Arizona is
pleased to offer DentalPlus, an easy-to-use plan
specifically designed to take care of your dental
needs. DentalPlus providers are available in Maricopa
and Pima counties.
Here’s a quick look at the major advantages
DentalPlus offers you:
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No deductibles
No claim forms (except for emergencies)
No precertification requirements
Discounted fees
No annual maximums
Emergency care
Covered Services:
Diagnostic Care
w Oral examinations and dental X-rays
Preventive Care
w Teeth cleaning (prophylaxis)
w Dietary planning and instruction on plaque
control and oral hygiene
Services Available for a Fee or a Discount off Billed Charges:
Restorations
w Regular fillings (silver amalgam, plastic, composite)
Periodontics
w Treatment of diseases of the gums and bones
that support teeth
Endodontics
w Root canal treatment
w Pulpotomy and treatment of dental pulp
Oral Surgery
w Simple and complicated extractions of the teeth
Prosthetics
w Crowns, bridges, partial dentures, dentures
Orthodontics
w Straightening of teeth (for adults and children)
Emergency Service
w Necessary to control bleeding, relieve pain or
eliminate acute infection (limited to $50
reimbursement per occurrence)
How DentalPlus works for you.
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When you sign up for DentalPlus, you’ll be able to
select your primary dentist from a list of contracted
DentalPlus dentists. The dentist you choose then
becomes your primary provider for all your dental
needs. If treatment is required that can’t be provided
by your primary dentist, you will be referred to a
participating DentalPlus specialist.
DentalPlus
odontic treatment. You may select any one of the
DentalPlus orthodontists, and, you will pay the
orthodontic fees listed in this brochure’s schedule
of covered orthodontic services.
Emergency services available too
If you have a dental emergency, you should contact
your DentalPlus primary dentist first. If you can’t
reach your DentalPlus dentist, or you are more
than 50 miles from home, you should seek care
immediately from any licensed dentist. You will be
reimbursed up to $50 for emergency dental treatment. Follow-up care must be administered by
your DentalPlus primary dentist.
No deductibles and affordable fees.
With DentalPlus, there are never any deductibles
to pay, and some covered diagnostic and preventive
services require no fees.
Services available through
DentalPlus.
Services listed on the fee schedule are available
when they are dentally necessary and performed by
your DentalPlus primary dentist operating within
the scope of his/her practice, provided they are not
an excluded service.
Blue Cross Blue Shield of Arizona or its designee
will interpret whether a service or supply is dentally
necessary under the terms of this plan. Patient care is
decided between the provider and the patient.
Services from a specialist
There may be times when your primary dentist
will need to refer you, or one of your enrolled
dependents, to a specialist for services that cannot
be done in his/her office. When you are referred
to a DentalPlus specialist, the fee schedule in this
brochure will not apply. The DentalPlus specialist
will provide services at a 25% discount off his/her
own billed charges. This does not apply to orth-
Other than this dental emergency care, there are
no benefits if you do not use a DentalPlus dentist.
Please note that prescription medications are not
covered under the DentalPlus Plan.
Applying for DentalPlus is easy.
Simply fill out the DentalPlus application with all
the requested information and follow the instructions on where to send the form. When you enroll
in DentalPlus you must select a DentalPlus dentist
to be your primary provider of dental care. Be sure
to indicate which dentist you have selected on
the application. If you are also enrolling your
dependents, they must use the same dentist you
have selected.
DentalPlus is simple to use.
After you have received your confirmation of enrollment, you may call your DentalPlus primary dentist
for an appointment after your effective date. Be sure
to mention that you are a DentalPlus member.
After you enroll, you’ll receive your contract/benefit
plan booklet, which will describe dental services
available through the DentalPlus Plan in greater
detail. Please read it carefully for all benefits, exclusions and limitations.
2
DentalPlus
DentalPlus: something to smile about.
Once you’ve had a chance to use DentalPlus, we’re certain
you’ll quickly see how easy it is to care for your dental health
— which is something you can definitely smile about.
DentalPlus is offered by Blue Cross Blue Shield of Arizona
and administered by a dental administrator* contracted with
BCBSAZ. Should you have any questions about enrolling in
DentalPlus for Individuals, please call Blue Cross Blue Shield
of Arizona at (877) 864-4899. For group coverage, please call
Blue Cross Blue Shield of Arizona at (602) 864-4260 or (800)
864-4400, extension 4260. Once your DentalPlus coverage
becomes effective, please call the DentalPlus administrator at
(888) 540-9488 for any questions you have about your coverage.
Exclusions and Limitations
The following is a partial list of conditions and services that are limited or excluded. A complete listing can be
found in the contract/benefit plan booklet, which will be sent to you when you enroll, or prior to enrollment
upon request.
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A service not rendered or authorized by your DentalPlus primary dentist, except for emergency treatment
Any procedures or services not listed on the DentalPlus Fee Schedule
Appliances or restoration necessary to increase vertical dimension or restore an occlusion
Complications related to an ineligible or excluded treatment, condition, procedure or service
Cosmetic or aesthetic services or surgery
Extractions of asymptomatic third molars
Orthodontic services or treatment that began before your effective date of coverage or continues
after your termination
Services or treatment associated with prior orthodontic treatment or services
Prescription and over-the-counter drugs
Repair or replacement of orthodontic appliances
Replacement of lost or stolen denture(s)
Services covered by Workers’ Compensation or similar benefits
Services or treatment for, or associated with, temporomandibular joint (TMJ) dysfunction or disorder,
or for orthognatic surgery
Services rendered by a hospital or other facility, or related to a hospital or facility visit
Services rendered before your effective date of coverage under this contract or after this coverage terminates
Services that are not approved by the American Dental Association (ADA), or those considered
investigational or experimental
Services that are not dentally necessary, as determined by Blue Cross Blue Shield of Arizona.
Important note: This brochure is a general summary. A complete description of any and all benefits, limitations and
exclusions is found in and governed by your contract/benefit plan booklet.
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* DentalPlus is administered by American Dental Professional Services, a separate and independent company contracted with BCBSAZ to provide administrative services.
Patient Fees
ADA
Code
Description of Services
fee
DIAGNOSTIC CARE
Clinical oral examinations
D0120 Periodic oral evaluation (every 6 months) . . . . . . . $ 0
D0140 Limited oral evaluation – problem focused . . . . . . . . 0
D0150 Comprehensive oral evaluation – new or
established patient . . . . . . . . . . . . . . . . . . . . . . . . . 0
D0170 Re-evaluation – limited, problem focused
(established patient; not post operative visit) . . . . . . 22
D0180 Comprehensive periodontal evaluation –
new or established patient . . . . . . . . . . . . . . . . . . . 36
Radiographs/Diagnostic Imaging (including
interpretation)
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0310
D0330
Intraoral – complete series (including bitewings) . $11
Intraoral – periapical first film . . . . . . . . . . . . . . . . . 0
Intraoral – periapical each additional film
Intraoral – occlusal film . . . . . . . . . . . . . . . . . . . . . 0
Extraoral – first film . . . . . . . . . . . . . . . . . . . . . . . . 0
Extraoral – each additional film . . . . . . . . . . . . . . . . 0
Bitewings – single film . . . . . . . . . . . . . . . . . . . . . . 0
Bitewings – two films . . . . . . . . . . . . . . . . . . . . . . . 0
Bitewings – four films . . . . . . . . . . . . . . . . . . . . . . . 0
Vertical bitewings – 7 to 8 films . . . . . . . . . . . . . . 40
Sialography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Panoramic film . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Test and Examinations
D0415 Collection of microorganisms for culture and
sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $17
D0416 Viral culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
D0425 Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . 14
D0431 Adjunctive pre-diagnostic test that aids in
detection of mucosal abnormalities including
permalignant and malignant lesions, not to
include cytology or biopsy procedures . . . . . . . . . . 25
D0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . 20
D0470 Diagnostic tests . . . . . . . . . . . . . . . . . . . . . . . . . . 50
ADA
Code
Description of Services
fee
Other Preventive Services
D1310 Nutritional counseling for control of
dental disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0
D1330 Oral hygiene instructions . . . . . . . . . . . . . . . . . . . . 0
Preventive sealants for permanent posterior teeth
(up to age 19)
D1351 Sealant – per tooth . . . . . . . . . . . . . . . . . . . . . . . . 25
Space Maintenance (passive appliances)
D1510
D1515
D1520
D1525
D1550
Space maintainer – fixed – unilateral . . . . . . . . . . 157
Space maintainer – fixed – bilateral . . . . . . . . . . . 207
Space maintainer – removable – unilateral . . . . . . 122
Space maintainer – removable – bilateral . . . . . . . 266
Re-cementation of space maintainer . . . . . . . . . . . 34
RESTORATIVE
Filings – Amalgam Restorations
D2140
D2150
D2160
D2161
Amalgam – one surface, primary or permanent . . $ 44
Amalgam – two surfaces, primary or permanent . . . 57
Amalgam – three surfaces, primary or permanent . . 71
Amalgam – four or more surfaces, primary or
permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Filings – Resin-Based Composite Restorations
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
Resin-based composite – one surface, anterior . . . $ 55
Resin-based composite – two surfaces, anterior . . . 70
Resin-based composite – three surfaces, anterior . . 86
Resin-based composite – four or more surfaces
or involving incisal angle (anterior) . . . . . . . . . . . 101
Resin-based composite crown, anterior . . . . . . . . 127
Resin-based composite – one surface, posterior . . . 64
Resin-based composite – two surfaces, posterior . . 82
Resin-based composite – three surfaces, posterior . 105
Resin-based composite – four or more surfaces,
posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Inlay/Onlay Restorations
PREVENTIVE CARE
Dental Prophylaxis (every 6 months)
D1110 Prophylaxis – adult . . . . . . . . . . . . . . . . . . . . . . . . $9
D1120 Prophylaxis – child . . . . . . . . . . . . . . . . . . . . . . . . . 7
Topical Fluoride Treatment (office procedure)
D1203 Topical application of fluoride (prophylaxis not
included – child) . . . . . . . . . . . . . . . . . . . . . . . . . . 0
D2510
D2520
D2530
D2542
D2543
D2544
D2610
Inlay – metallic – one surfaces . . . . . . . . . . . . . . $310
Inlay – metallic – two surfaces . . . . . . . . . . . . . . . 353
Inlay – metallic – three or more surfaces . . . . . . . 407
Onlay – metallic – two surfaces . . . . . . . . . . . . . . 399
Onlay – metallic – three surfaces . . . . . . . . . . . . . 417
Onlay – metallic – four or more surfaces . . . . . . 434
Inlay – porcelain/ceramic – one surface . . . . . . . . 366
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
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Patient Fees
ADA
Code
Description of Services
fee
RESTORATIVE (Continued)
D2620 Inlay – porcelain/ceramic – two surfaces . . . . . . $387
D2630 Inlay – porcelain/ceramic – three or more
surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
D2642 Onlay – porcelain/ceramic – two surfaces . . . . . . 400
D2643 Onlay – porcelain/ceramic – three surfaces . . . . . 431
D2644 Onlay – porcelain/ceramic –
four or more surfaces . . . . . . . . . . . . . . . . . . . . . 458
D2650 Inlay – resin-based composite – one surface . . . . . 241
D2651 Inlay – resin-based composite – two surfaces . . . . 281
D2652 Inlay – resin-based composite –
three or more surfaces . . . . . . . . . . . . . . . . . . . . .301
D2662 Onlay – resin-based composite – two surfaces . . . 275
D2663 Onlay – resin-based composite – three surfaces . . 310
D2664 Onlay – resin-based composite –
four or more surfaces . . . . . . . . . . . . . . . . . . . . . 330
Crowns – Single Restoration Only
D2710 Crown – resin-based composite (indirect) . . . . . $201
D2712 Crown – resin-based composite (indirect)
This code does not include facial veneers . . . . . . . 196
D2720 Crown – resin with high noble metal . . . . . . . . . 458
D2721 Crown – resin with predominantly base metal . . . 429
D2722 Crown – resin with noble metal . . . . . . . . . . . . . 438
D2740 Crown – porcelain/ceramic substrate . . . . . . . . . 469
D2750 Crown – porcelain fused to high noble metal . . . . 463
D2751 Crown – porcelain fused to predominantly
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
D2752 Crown – porcelain fused to noble metal . . . . . . . 442
D2780 Crown – 3/4 cast high noble metal . . . . . . . . . . . 445
D2781 Crown – 3/4 cast predominantly base metal . . . . 419
D2782 Crown – 3/4 cast noble metal . . . . . . . . . . . . . . . 432
D2783 Crown – 3/4 porcelain/ceramic . . . . . . . . . . . . . 457
D2790 Crown – full cast high noble metal . . . . . . . . . . . 445
D2791 Crown – full cast predominantly base metal . . . . . 423
D2792 Crown – full cast noble metal . . . . . . . . . . . . . . . 431
D2794 Crown – titanium . . . . . . . . . . . . . . . . . . . . . . . 445
Other Restorative Services
D2910 Recement inlay, onlay, or partial coverage
restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 36
D2915 Recement cast or prefabricated post and core . . . . .36
D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . 38
D2930 Prefabricated stainless steel crown –
primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
D2931 Prefabricated stainless steel crown –
permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . 118
D2932 Prefabricated resin crown . . . . . . . . . . . . . . . . . . 128
5
ADA
Code
Description of Services
fee
D2933 Prefabricated stainless steel crown with
resin window . . . . . . . . . . . . . . . . . . . . . . . . . . $144
D2934 Prefabricated esthetic coated stainless steel crown –
primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
D2950 Core buildup, including any pins . . . . . . . . . . . . . 99
D2951 Pin retention – per tooth, in addition
to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
D2952 Cast post and core addition to crown . . . . . . . . . 152
D2953 Each additional cast post – same tooth . . . . . . . . . . 75
D2954 Prefabricated post and core in addition to crown . 125
D2955 Post removal (not in conjunction with
endodontic therapy) . . . . . . . . . . . . . . . . . . . . . . . 94
D2957 Each additional prefabricated post – same tooth . . . 63
D2960 Labial veneer (resin laminate) – chairside . . . . . . . 178
D2961 Labial veneer (resin laminate) – laboratory . . . . . . 344
D2962 Labial veneer (porcelain laminate) – laboratory . . . 373
D2971 Additional procedures to construct new crown
under existing partial denture framework . . . . . . . . 53
D2975 Coping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
D2980 Crown repair, by report . . . . . . . . . . . . . . . . . . . . 34
D2999 Unspecified restorative procedure, by report . . . . . 56
ENDODONTICS
Pulp Capping
D3110 Pulp cap – direct (excluding final restoration) . . . $28
D3120 Pulp cap – indirect (excluding final restoration) . . . 21
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration)
– removal of pulp coronal to the dentinocemental
junction and application of medicament . . . . . . . $64
D3221 Pulpal debridgement, primary and
permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Endodontic Therapy on Primary Teeth
D3230 Pulpal therapy (resorbable filling) – anterior,
primary tooth (excluding final restoration) . . . . . . $68
D3240 Pulpal therapy (resorbable filling) – posterior,
primary tooth (excluding final restoration) . . . . . . . 73
Root Canal Therapy (including treatment plan, clinical
procedures and follow-up care)
D3310 Anterior (excluding final restoration) . . . . . . . . . $271
D3320 Bicuspid (excluding final restoration) . . . . . . . . . . 325
D3330 Molar (excluding final restoration) . . . . . . . . . . . . 429
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
Patient Fees
ADA
Code
Description of Services
fee
ENDODONTICS (Continued)
D3331 Treatment of root canal obstruction;
non-surgical access . . . . . . . . . . . . . . . . . . . . . . . $ 92
D3332 Incomplete endodontic therapy; inoperable,
unrestorable or fractured tooth . . . . . . . . . . . . . . 131
D3333 Internal root repair of perforation defects . . . . . . . . 79
ADA
Code
Description of Services
fee
PERIDONTICS
Surgical Services (including usual postoperative care)
D3410 Apicoectomy/periradicular surgery – anterior . . $310
D3421 Apicoectomy/periradicular surgery – bicuspid
(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
D3425 Apicoectomy/periradicular surgery – molar
(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
D3426 Apicoectomy/periradicular surgery –
each additional root . . . . . . . . . . . . . . . . . . . . . . 113
D3430 Retrograde filling – per root . . . . . . . . . . . . . . . . . 94
D3450 Root amputation – per root . . . . . . . . . . . . . . . . 193
D3460 Endodontic endosseous implant . . . . . . . . . . . . . 552
D3470 Intentional reimplantation (including
necessary splinting) . . . . . . . . . . . . . . . . . . . . . . . 380
D4210 Gingivectomy or gingivoplasty – four or more
contiguous teeth or bounded teeth spaces per
quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $204
D4211 Gingivectomy or gingivoplasty – one to three
contiguous teeth or bounded teeth spaces
per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
D4240 Gingival flap procedure, including root planning
– four or more contiguous teeth or bounded teeth
spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 339
D4241 Gingival flap procedure, including root planning –
one to three contiguous teeth or bounded teeth
spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 175
D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . 251
D4249 Clinical crown lengthening – hard tissue . . . . . . . 279
D4260 Osseous surgery (including flap entry and closure)
– four or more contiguous teeth or bounded teeth
spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 547
D4261 Osseous surgery (including flap entry and closure) –
one to three contiguous teeth or bounded teeth
spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 285
D4266 Guided tissue regeneration – resorbable barrier,
per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
D4267 Guided tissue regeneration – nonresorbable
barrier, per site (includes membrane removal) . . . 257
D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . 321
D4271 Free soft tissue graft procedure
(including donor site surgery) . . . . . . . . . . . . . . . 416
D4273 Subepithelial connective tissue graft procedures,
per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
D4274 Distal or proximal wedge procedure (when not
performed in conjunction with surgical procedures
in the same anatomical area) . . . . . . . . . . . . . . . . 189
D4275 Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . 250
D4276 Combined connective tissue and double
pedicle graft, per tooth . . . . . . . . . . . . . . . . . . . . 307
Other Endodontic Procedures
Non-surgical Periodontal Services
D3910 Surgical procedure for isolation of tooth with
rubber dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 49
D3920 Hemisection (including any root removal),
not including root canal therapy . . . . . . . . . . . . . 150
D3950 Canal preparation and fitting of preformed
dowel or post . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
D4320 Provisional splinting – intracoronal . . . . . . . . . . $206
D4321 Provisional splinting – extracoronal . . . . . . . . . . . 167
D4341 Periodontal scaling and root planning –
four or more teeth per quadrant . . . . . . . . . . . . . 111
D4342 Periodontal scaling and root planning –
one to three teeth per quadrant . . . . . . . . . . . . . . . 61
D4355 Full mouth debridement to enable
comprehensive evaluation and diagnosis . . . . . . . . 74
Endodontic Retreatment
D3346 Retreatment of previous root canal therapy –
anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $366
D3347 Retreatment of previous root canal therapy –
bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
D3348 Retreatment of previous root canal therapy –
molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Apexification/recalcification Procedures
D3351 Apexification/recalcification – initial visit
(apical closure/calcific repair of perforations,
root resorption, etc.) . . . . . . . . . . . . . . . . . . . . . . $ 99
D3352 Apexification/recalcification – interim medication
replacement (apical closure/calcific repair of
perforations, root resorption, etc.) . . . . . . . . . . . . . 68
D3353 Apexification/recalcification – final visit (includes
completed root canal therapy – apical closure/calcific
repair of perforations, root resorption, etc.) . . . . . 217
Apicoectomy/periradicular Services
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
6
Patient Fees
ADA
Code
Description of Services
fee
PERIDONTICS (Continued)
Other Periodontal Services
D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . $65
D4920 Unscheduled dressing change
(by someone other than treating dentist) . . . . . . . . 33
D4999 Unspecified periodontal procedure, by report . . . . 17
PROSTHODONTICS (removable)
Complete Dentures (including routine
post-delivery care) D5110
D5120
D5130
D5140
Complete denture – maxillary . . . . . . . . . . . . . $545
Complete denture – mandibular . . . . . . . . . . . . . 545
Immediate denture – maxillary . . . . . . . . . . . . . . 594
Immediate denture – mandibular . . . . . . . . . . . . . 594
Partial Dentures (including routine post-delivery care)
D5211 Maxillary partial denture – resin base
(including any conventional clasps, rests and teeth) $459
D5212 Mandibular partial denture – resin base
(including any conventional clasps, rests and teeth) . 533
D5213 Maxillary partial denture – cast metal framework
with resin denture bases (including any
conventional clasps, rests and teeth) . . . . . . . . . . . 601
D5214 Mandibular partial denture – cast metal
framework with resin denture bases (including
any conventional clasps, rests and teeth) . . . . . . . . 601
D5225 Maxillary partial denture – flexible base
(including any clasps, rests and teeth) . . . . . . . . . . 459
D5226 Mandibular partial denture – flexible base
(including any clasps, rests and teeth) . . . . . . . . . . 533
D5281 Removable unilateral partial denture –
one piece cast metal (including clasps and teeth) . . 351
Adjustments to Dentures
D5410
D5411
D5421
D5422
7
Adjust complete denture – maxillary . . . . . . . . . . $31
Adjust complete denture – mandibular . . . . . . . . . 31
Adjust partial denture – maxillary . . . . . . . . . . . . . 31
Adjust partial denture – mandibular . . . . . . . . . . . . 31
ADA
Code
Description of Services
fee
Repairs to Complete Dentures
D5510 Repair broken complete denture base . . . . . . . . . $60
D5520 Replace missing or broken teeth –
complete denture (each tooth) . . . . . . . . . . . . . . . 49
Repairs to Partial Dentures
D5610
D5620
D5630
D5640
D5650
D5660
D5670
Repair resin denture base . . . . . . . . . . . . . . . . . . $ 64
Repair cast framework . . . . . . . . . . . . . . . . . . . . . 69
Repair or replace broken clasp . . . . . . . . . . . . . . . 75
Replace broken teeth – per tooth . . . . . . . . . . . . . 53
Add tooth to existing partial denture . . . . . . . . . . . 75
Add clasp to existing partial denture . . . . . . . . . . . 78
Replace all teeth and acrylic on cast metal
framework (maxillary) . . . . . . . . . . . . . . . . . . . . 266
D5671 Replace all teeth and acrylic on cast metal
framework (mandibular) . . . . . . . . . . . . . . . . . . . 266
Denture Rebase Procedures
D5710
D5711
D5720
D5721
Rebase complete maxillary denture . . . . . . . . . . $220
Rebase complete mandibular denture . . . . . . . . . 206
Rebase maxillary partial denture . . . . . . . . . . . . . 182
Rebase mandibular partial denture . . . . . . . . . . . 208
Denture Reline Procedures
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
Reline complete maxillary denture (chairside) . . $125
Reline complete mandibular denture (chairside) . 125
Reline maxillary partial denture (chairside) . . . . . 115
Reline mandibular partial denture (chairside) . . . . 115
Reline complete maxillary denture (laboratory) . . 167
Reline complete mandibular denture (laboratory) 167
Reline maxillary partial denture (laboratory) . . . . 164
Reline mandibular partial denture (laboratory) . . . 164
Interim Prosthesis
D5810
D5811
D5820
D5821
Interim complete denture (maxillary) . . . . . . . . $263
Interim complete denture (mandibular) . . . . . . . . 283
Interim partial denture (maxillary) . . . . . . . . . . . . 204
Interim partial denture (mandibular) . . . . . . . . . . 217
Other Removable Prosthetic Services
D5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . .$52
D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . 52
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
Patient Fees
ADA
Code
Description of Services
fee
PROSTHODONTICS, FIXED
Fixed Partial Denture Pontics
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
Pontic – indirect resin based composite . . . . . . . $271
Pontic – cast high noble metal . . . . . . . . . . . . . . 416
Pontic – cast predominantly base metal . . . . . . . . 390
Pontic – cast noble metal . . . . . . . . . . . . . . . . . . 406
Pontic – titanium . . . . . . . . . . . . . . . . . . . . . . . . 419
Pontic – porcelain fused to high noble metal . . . . 410
Pontic – porcelain fused to predominantly
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Pontic – porcelain fused to noble metal . . . . . . . . 400
Pontic – porcelain/ceramic . . . . . . . . . . . . . . . . . 436
Pontic – resin with high noble metal . . . . . . . . . . 406
Pontic – resin with predominately base metal . . . . 373
Pontic – resin with noble metal . . . . . . . . . . . . . . 386
Provisional pontic . . . . . . . . . . . . . . . . . . . . . . . 174
Fixed Partial Denture Retainers – Inlays/Onlays
D6545 Retainer – cast metal for resin bonded fixed
prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $173
D6548 Retainer – porcelain/ceramic for resin bonded
fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . 196
D6600 Inlay – porcelain/ceramic, two surfaces . . . . . . . . 343
D6601 Inlay – porcelain/ceramic, three or more surfaces . 359
D6602 Inlay – cast high noble metal, two surfaces . . . . . . 366
D6603 Inlay – cast high noble metal, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
D6604 Inlay – cast predominantly base metal,
two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
D6605 Inlay – cast predominantly base metal,
three or more surfaces . . . . . . . . . . . . . . . . . . . . .380
D6606 Inlay – cast noble metal, two surfaces . . . . . . . . . 353
D6607 Inlay – cast noble metal, three or more surfaces . . 391
D6624 Inlay - titanium . . . . . . . . . . . . . . . . . . . . . . . . . 366
D6608 Onlay – porcelain/ceramic, two surfaces . . . . . . . 377
D6609 Onlay – porcelain/ceramic, three or more surfaces 389
D6610 Onlay – cast high noble metal, two surfaces . . . . . 395
D6611 Onlay – cast high noble metal, three or
more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
D6612 Onlay – cast predominantly base metal,
two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
ADA
Code
Description of Services
fee
D6613 Onlay – cast predominantly base metal,
three or more surfaces . . . . . . . . . . . . . . . . . . . . $410
D6614 Onlay – cast noble metal, two surfaces . . . . . . . . . 388
D6615 Onlay – cast noble metal, three or more surfaces . . 407
D6634 Onlay – titanium . . . . . . . . . . . . . . . . . . . . . . . . 366
Fixed Partial Denture Retainers - Crowns
D6710
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6794
D6793
Crown – indirect resin based composite . . . . . . $392
Crown – resin with high noble metal . . . . . . . . . 458
Crown – resin with predominantly base metal . . . 434
Crown – resin with noble metal . . . . . . . . . . . . . 442
Crown – porcelain/ceramic . . . . . . . . . . . . . . . . 481
Crown – porcelain fused to high noble metal . . . . 469
Crown – porcelain fused to predominantly
bas metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Crown – porcelain fused to noble metal . . . . . . . 448
Crown 3/4 cast high noble metal . . . . . . . . . . . . 442
Crown 3/4 cast predominantly base metal . . . . . 442
Crown 3/4 cast noble metal . . . . . . . . . . . . . . . . 410
Crown 3/4 porcelain/ceramic . . . . . . . . . . . . . . .455
Crown - full cast high noble metal . . . . . . . . . . . 452
Crown – full cast predominantly base metal . . . . . 429
Crown – full cast noble metal . . . . . . . . . . . . . . . 445
Crown – titanium . . . . . . . . . . . . . . . . . . . . . . . 445
Provisional retainer crown . . . . . . . . . . . . . . . . . 161
Other Fixed Partial Denture Services
D6920
D6930
D6940
D6950
D6970
Connector bar . . . . . . . . . . . . . . . . . . . . . . . . . $229
Recement fixed partial denture . . . . . . . . . . . . . . 55
Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Precision attachment . . . . . . . . . . . . . . . . . . . . . 191
Post and core in addition to fixed
partial denture retainer . . . . . . . . . . . . . . . . . . . . 153
D6972 Prefabricated post and core in addition to fixed
partial denture retainer . . . . . . . . . . . . . . . . . . . . 123
D6973 Core build up for retainer, including any pins . . . . 99
D6975 Coping – metal . . . . . . . . . . . . . . . . . . . . . . . . . 230
D6976 Each additional indirectly fabricated post –
same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 64
D6977 Each additional prefabricated post – same tooth . . . 62
D6980 Fixed partial denture repair, by report . . . . . . . . . 57
D6985 Pediatric partial denture, fixed . . . . . . . . . . . . . . . 209
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
8
Patient Fees
ADA
Code
Description of Services
fee
ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing,
if needed, and routine postoperative care)
D7111 Extraction – coronal remnants –
deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . $41
D7140 Extraction – erupted tooth or exposed root
(elevation and/or forceps removal) . . . . . . . . . . . . 56
Surgical Extractions (includes local anesthesia, suturing
if needed, and Routine Postoperative Care)
D7210 Surgical removal of erupted tooth requiring elevation
or mucoperiosteal flap and removal of bone and/or
section of tooth . . . . . . . . . . . . . . . . . . . . . . . . . $ 96
D7220 Removal of impacted tooth – soft tissue . . . . . . . 119
D7230 Removal of impacted tooth – partially bony . . . . 160
D7240 Removal of impacted tooth – completely bony . . 188
D7241 Removal of impacted tooth – completely bony,
with unusual surgical complications . . . . . . . . . . . 236
D7250 Surgical removal of residual tooth roots
(cutting procedure) . . . . . . . . . . . . . . . . . . . . . . . 101
Other Surgical Procedures
D7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . $332
D7261 Primary closure of a sinus perforation . . . . . . . . . 273
D7270 Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth . . . . . . . . . 194
D7280 Surgical access of an unerupted tooth . . . . . . . . . 174
D7282 Mobilization of erupted or malpositioned tooth
to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
D7283 Placement of device to facilitate eruption of
impacted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
D7285 Biopsy of oral tissue – hard (bone, tooth) . . . . . . . 150
D7286 Biopsy of oral tissue – soft . . . . . . . . . . . . . . . . . . 150
D7287 Exfoliative cytological sample collection . . . . . . . . 80
D7288 Brush biopsy – transepithelial sample collection . . . 40
Alveoloplasty – Surgical Preparation of Ridge for
Dentures
D7310 Alveoloplasty in conjunction with extractions –
per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . $112
D7311 Alveoloplasty in conjunction with extractions –
one to three teeth or tooth spaces – per quadrant . . 89
D7320 Alveoloplasty not in conjunction with extractions –
per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
D7321 Alveoloplasty not in conjunction with extractions
one to three teeth or tooth spaces, per quadrant . . 136
Vestibuloplasty
9
ADA
Code
Description of Services
fee
D7340 Vestibuloplasty – ridge extension
(secondary epithelialization) . . . . . . . . . . . . . . . $320
D7350 Vestibuloplasty – ridge extension (including soft
tissue grafts, muscle reattachment, revision of
soft tissue attachment and management of
hypertrophied and hyperplastic tissue) . . . . . . . . . 843
Surgical Excision of Soft Tissue Lesions
D7410
D7411
D7412
D7413
D7414
D7415
D7465
Excision of benign lesion up to 1.25 cm . . . . . . $110
Excision of benign lesion greater than 1.25 cm . . 261
Excision of benign lesion, complicated . . . . . . . . 306
Excision of malignant lesion up to 1.25 cm . . . . . 233
Excision of malignant lesion greater than 1.25 cm . 344
Excision of malignant lesion, complicated . . . . . . 361
Destruction of lesions by physical or chemical
method, by report . . . . . . . . . . . . . . . . . . . . . . . . 83
Surgical Excision of Intra-osseous Lesions
D7440 Excision of malignant tumor – lesion diameter
up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . $228
D7441 Excision of malignant tumor – lesion diameter
greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . 339
D7450 Removal of benign odontogenic cyst or tumor –
lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . 169
D7451 Removal of benign odontogenic cyst or tumor –
lesion diameter greater than 1.25 cm . . . . . . . . . . 217
D7460 Removal of benign nonodontogenic cyst or tumor –
lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . 123
D7461 Removal of benign nonodontogenic cyst or tumor –
lesion diameter greater than 1.25 cm . . . . . . . . . . 172
Excision of Bone Tissue
D7471
D7472
D7473
D7485
D7490
Removal of lateral exostosis (maxilla or mandible) . 277
Removal of torus palatinus . . . . . . . . . . . . . . . . . 388
Removal of torus mandibularis . . . . . . . . . . . . . . 407
Surgical reduction of osseous tuberosity . . . . . . . . 317
Radical resection of maxilla or mandible . . . . . . 2,980
Surgical Incision
D7510 Incision and drainage of abscess –
intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . $ 83
D7511 Incision and drainage of abscess – intraoral soft
tissue – complicated (includes drainage of multiple
fascial spaces) . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
D7520 Incision and drainage of abscess –
extraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . 150
D7521 Incision and drainage of abscess – extraoral
soft tissue – complicated (includes drainage
of multiple fascial spaces) . . . . . . . . . . . . . . . . . . 359
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
Patient Fees
ADA
Code
Description of Services
fee
ORAL AND MAXILLOFACIAL SURGERY(Con’t)
D7530 Removal of foreign body from mucosa, skin,
or subcutaneous alveolar tissue . . . . . . . . . . . . . $104
D7540 Removal of reaction producing foreign bodies,
musculoskeletal system . . . . . . . . . . . . . . . . . . . . 128
D7550 Partial ostectomy/sequestrectomy for removal
of non-vital bone . . . . . . . . . . . . . . . . . . . . . . . . 127
D7560 Maxillary sinusotomy for removal of tooth
fragment or foreign body . . . . . . . . . . . . . . . . . . 406
Treatment of Fractures – Simple
D7610 Maxilla – open reduction (teeth immobilized,
if present . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,627
D7620 Maxilla – closed reduction (teeth immobilized,
if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,220
D7630 Mandible – open reduction (teeth immobilized,
if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,115
D7640 Mandible – closed reduction (teeth immobilized,
if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,220
D7650 Malar and/or zygomatic arch – open reduction . 1,018
D7660 Malar and/or zygomatic arch – closed reduction . 599
D7670 Alveolus – closed reduction may include
stabilization of teeth . . . . . . . . . . . . . . . . . . . . . . 381
D7671 Alveolus – open reduction, may include
stabilization of teeth . . . . . . . . . . . . . . . . . . . . . 1,021
D7680 Facial bones – complicated reduction with
fixation and multiple surgical approaches . . . . . . 3,051
Treatment of Fractures – Compound
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
Maxilla – open reduction . . . . . . . . . . . . . . . . $1,912
Maxilla – closed reduction . . . . . . . . . . . . . . . . 1,326
Mandible – open reduction . . . . . . . . . . . . . . . . 2,274
Mandible – closed reduction . . . . . . . . . . . . . . . 1,369
Malar and/or zygomatic arch – open reduction . . 1,740
Malar and/or zygomatic arch – closed reduction . . 766
Alveolus – open reduction stabilization of teeth . . . 805
Alveolus – closed reduction stabilization of teeth . . 754
Facial bones – complicated reduction with
fixation and multiple surgical approaches . . . . . . 3,982
Repair of Traumatic Wounds
D7910 Suture of recent small wounds up to 5 cm . . . . . $117
Complicated Suturing (reconstruction requiring
delicate handling of tissues and wide undermining for
meticulous closure)
ADA
Code
Description of Services
fee
Other Repair Procedures
D7920 Skin graft (identify defect covered, location
and type of graft) . . . . . . . . . . . . . . . . . . . . . . $1,199
D7960 Frenulactomy (frenectomy or frenotomy) –
separate procedure . . . . . . . . . . . . . . . . . . . . . . . . 99
D7963 Frenuloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
D7970 Excision of hyperplastic tissue – per arch . . . . . . . 169
D7971 Excision of pericoronal gingiva . . . . . . . . . . . . . . . 78
D7972 Surgical reduction of fibrous tuberosity . . . . . . . . 139
D7980 Sialolithotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 217
D7981 Excision of salivary gland, by report . . . . . . . . . . 558
D7982 Sialodochoplasty . . . . . . . . . . . . . . . . . . . . . . . . . 610
D7983 Closure of salivary fistula . . . . . . . . . . . . . . . . . . 228
D7990 Emergency tracheotomy . . . . . . . . . . . . . . . . . . . 406
D7997 Appliance removal (not by dentist who placed
appliance), includes removal of archbar) . . . . . . . . 125
ORTHODONTICS
Orthodontic PLAN benefits cover 24 months of usual and
customary orthodontic treatment. You are responsible to pay
for initial diagnostic workup, X-rays and retention
Limited Orthodontic Treatment
D8010 Limited orthodontic treatment of the
primary dentition . . . . . . . . . . . . . . . . . . . . . . $1,080
D8020 Limited orthodontic treatment of the
transitional dentition . . . . . . . . . . . . . . . . . . . . . 1,050
D8030 Limited orthodontic treatment of the
adolescent dentition . . . . . . . . . . . . . . . . . . . . . 1,080
D8040 Limited orthodontic treatment of the
adult dentition . . . . . . . . . . . . . . . . . . . . . . . . . . 984
Interceptive Orthodontic Treatment
D8050 Interceptive orthodontic treatment of the
primary dentition . . . . . . . . . . . . . . . . . . . . . . $1,132
D8060 Interceptive orthodontic treatment of the
transitional dentition . . . . . . . . . . . . . . . . . . . . 1,139
Comprehensive Orthodontic Treatment
D8070 Comprehensive orthodontic treatment of
the transitional dentition . . . . . . . . . . . . . . . . . $2,273
D8080 Comprehensive orthodontic treatment of
the adolescent dentition . . . . . . . . . . . . . . . . . . 2,544
D8090 Comprehensive orthodontic treatment of
the adult dentition . . . . . . . . . . . . . . . . . . . . . . 2,632
D7911 Complicated suture – up to 5 cm . . . . . . . . . . . . $ 56
D7912 Complicated suture – greater than 5 cm . . . . . . . 320
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
10
Patient Fees
ADA
Code
Description of Services
fee
ADJUNCTIVE GENERAL SERVICES
ADA
Code
Description of Services
fee
Professional Consultation
Unclassified Treatment
D9310 Consultation by dentist or physician other than
requesting dentist or physician . . . . . . . . . . . . . . $44
D9110 Palliative (emergency) treatment of dental pain –
minor procedure . . . . . . . . . . . . . . . . . . . . . . . . $35
Professional Visits
Anesthesia
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
Regional block anesthesia . . . . . . . . . . . . . . . . . . $ 24
Trigeminal division block anesthesia . . . . . . . . . . . 48
Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Deep sedation/general anesthesia –
first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . 137
Deep sedation/general anesthesia –
each additional 15 minutes . . . . . . . . . . . . . . . . . . 57
Analgesia, anxiolysis, inhalation of nitrous oxide . . 19
Intravenous conscious sedation/analgesia –
first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . 108
Intravenous conscious sedation/analgesia –
each additional 15 minutes . . . . . . . . . . . . . . . . . . 46
Non-intravenous conscious sedation . . . . . . . . . . . 42
D9440 Office visit – after regularly scheduled hours . . . . $44
Miscellaneous Services
D9910 Application of desensitizing medicament . . . . . . . $ 13
D9911 Application of desensitizing resin for
cervical and/or root surface, per tooth . . . . . . . . . . 22
D9930 Treatment of complications (post-surgical)unusual circumstances, by report . . . . . . . . . . . . . . 39
D9951 Occlusal adjustment – limited . . . . . . . . . . . . . . . . 28
D9952 Occlusal adjustment – complete . . . . . . . . . . . . . 170
D9999 Unspecified adjunctive procedure, by report . . . . . 28
11-0115
Fees listed apply only when services are performed by your DentalPlus primary dentist.
If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges.
D2613 0108
2613 0211