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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 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 Blue Cross Blue Shield Service Benefit Plan brochure.

2013 Standard Option - Dental Benefits

Routine Dental Care Fee Schedule

Clinical Oral Evaluations

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


All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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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Dental Radiology

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

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Palliative or Emergency Treatment

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • Sedative filling
$24$15

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Preventive

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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)

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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)

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

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Extractions — Includes local anesthesia and routine post-operative care

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

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

  • 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
Not covered: Any service not specifically listed aboveNothingNothingAll charges

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Service

ServicePreferred ProviderNon-Participating Provider
  • 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 for inpatient care.

Inpatient: In full after $250 per admission copayment

Unlimited days

Outpatient: Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance (PPA)

Inpatient: $350 per admission copayment

35% of the Plan Allowance (PA)

You may also pay the difference between the provider's charge and our payment

Unlimited days

Outpatient: Subject to the calendar year deductible (Individual or Family)

35% 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)

35% of the Plan Allowance
(physician care)

35% 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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Page last updated: December 31, 2012

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