Dental
Dental

Standard Option features a variety of dental benefits. Select from one of our Preferred providers, or choose a practitioner outside of the network — it's up to you. Standard Option affords you the freedom to see the dentist of your choice. Under Standard Option, we pay billed charges up to the fee schedule amount for covered dental services — these routine services have no deductibles, copayments or coinsurance.

If you are also enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, the Service Benefit Plan will be the primary payer for any covered dental services and your FEDVIP Plan will be secondary to the Service Benefit Plan. See Section 9, Coordinating benefits with other coverage, of the 2009 Blue Cross Blue Shield Service Benefit Plan brochure for additional information.

Preferred dentists agree to file your claims with us and accept a negotiated, discounted amount called the maximum allowable charge (MAC) as payment in full for these services. When you use a Preferred dentist, you are responsible for the difference between the fee schedule amount and the MAC.

When you use a Non-preferred dentist, you pay all charges in excess of the fee schedule amount.

Learn more about your coverage and copayments using the table below. This is a complete list of the covered dental procedures and fee schedule amounts. Any service that is not listed is not covered. Please remember that all benefits are subject to the definitions, limitations, and exclusions defined in the 2009 Blue Cross Blue Shield Service Benefit Plan brochure.

2009 Standard Option - Dental Benefits

Routine Dental Care Fee Schedule

Clinical Oral Evaluations

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Periodic oral evaluation*
 $12 $8

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Limited oral evaluation
 $14 $9
  • Comprehensive oral evaluation
 $14 $9
  • Detailed and extensive oral evaluation
 $14 $9

*Limited to two per person per calendar year

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Radiographs

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Intraoral complete series
 $36 $22

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Intraoral periapical first film
 $7 $5
  • Intraoral periapical each additional film
 $4 $3
  • Intraoral occlusal film
 $12 $7
  • Extraoral first film
 $16 $10
  • Extraoral each additional film
 $6 $4
  • Bitewing — single film
 $9 $6
  • Bitewings — two films
 $14 $9
  • Bitewings — four films
 $19 $12
  • Bitewings — vertical
 $12 $7
  • Posterior — anterior or lateral skull and facial bone survey film
 $45 $28
  • Panoramic film
 $36 $23

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Tests And Laboratory Exams

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Pulp vitality tests
 $11 $7

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge

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Palliative Or Emergency Treatment

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Palliative (emergency) treatment of dental pain — minor procedure
 $24 $15

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Sedative filling
 $24 $15

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Preventive

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Prophylaxis —
    adult*
 ——— $16

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Prophylaxis —
    child*
 $22 $14
  • Topical Application of fluoride, prophylaxis not included — child
 $13 $8
  • Topical Application of fluoride, prophylaxis not included — adult
 ——— $8

*Limited to two per person per calendar year

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Space Maintenance (passive appliances)

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Space maintainer
    – fixed
    – unilateral
 $94 $59

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Space maintainer
    – fixed
    – bilateral
 $139 $87
  • Space maintainer
    – removable
    – unilateral
 $94 $59
  • Space maintainer
    – removable
    – bilateral
 $139 $87
  • Recementation of space maintainer
 $22 $14

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Amalgam Restorations (including polishing)

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Amalgam —
    one surface, primary or permanent
 $25 $16

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Amalgam —
    two surfaces, primary or permanent
 $37 $23
  • Amalgam —
    three surfaces, primary or permanent
 $50 $31
  • Amalgam —
    four or more surfaces, primary or permanent
 $56 $35

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Filled Or Unfilled Resin Restorations

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Resin —
    one surface, anterior
 $25 $16

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Resin —
    two surfaces, anterior
 $37 $23
  • Resin —
    three surfaces, anterior
 $50 $31
  • Resin —
    four or more surfaces or involving incisal angle (anterior)
 $56 $35
  • Resin-based composite —
    one surface, posterior
 $25 $16
  • Resin-based composite —
    two surfaces, posterior
 $37 $23
  • Resin-based composite —
    three surfaces, posterior
 $50 $31
  • Resin-based composite —
    four or more surfaces, posterior
 $50 $31

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Inlay Restorations

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Inlay — metallic — one surface
 $25 $16

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Inlay —
    metallic – two surfaces
 $37 $23
  • Inlay —
    metallic – three or more surfaces
 $50 $31
  • Inlay —
    porcelain/ceramic – one surface
 $25 $16
  • Inlay —
    porcelain/ceramic – two surfaces
 $37 $23
  • Inlay —
    porcelain/ceramic – three or more surfaces
 $50 $31
  • Inlay —
    composite/resin – one surface
 $25 $16
  • Inlay —
    composite/resin – two surfaces
 $37 $23
  • Inlay —
    composite/resin – three or more surfaces
 $50 $31

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Other Restorative Services

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Pin retention — per tooth, in addition to restoration
 $13 $8

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge

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Extractions — Includes local anesthesia and routine post-operative care

Services We Pay
(to age 13)		 We Pay
(age 13+)		 You Pay
  • Extraction, erupted tooth or exposed root
 $30 $19

Preferred: Up to the MAC

Non-preferred: Up to the provider's charge
  • Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth
 $43 $27
  • Surgical removal of residual tooth roots (cutting procedure)
 $71 $45
  • General anesthesia in connection with covered extractions
 $43 $27

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Service

Service Preferred Provider Non-Participating Provider
  • Inpatient and Outpatient Hospital Care

    For severe dental caries in children up to age 22 and for other types of dental procedures when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

    Precertification required.

In full after $200 per admission copayment

Unlimited days

$300 per admission copayment

30% of the Plan Allowance (PA) for care in Non-member hospitals

You also pay the difference between the provider's charge and our paymentthe Plan Allowance when you use Non-member facilities.

Unlimited days
  • Oral And Maxillofacial Surgery

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance (PPA)

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance

You also pay the difference between the provider's charge and the Plan Allowance when you use Non-participating physicians
  • Accidental Dental Injury

Subject to the calendar year deductible (Individual or Family)

15% PPA
(physician care)

15% PPA
(facility care)

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance
(physician care)

30% of the Plan Allowance
(facility care)

You also pay the difference between the provider's charge and the Plan Allowance when you use Non-participating physicians or Non-member hospitals.

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