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Dental Blue for Federal Employees - Standard Option Copayment Schedule

Code
Covered Service
Copayment1
To Age 13 Age 13 and Over
Clinical Oral Evaluations

D0120

Periodic oral evaluation*

$12

$8

D0140

Limited oral evaluation

$14

$9

D0150

Comprehensive oral evaluation

$14

$9

D0160

Detailed and extensive oral evaluation

$14

$9

* Limited to two per person per calendar year

Radiographs

D0210

Intraoral complete series

$36

$22

D0220

Intraoral periapical first film

$7

$5

D0230

Intraoral periapical each additional film

$4

$3

D0240

Intraoral occlusal film

$12

$7

D0250

Extraoral first film

$16

$10

D0260

Extraoral each additional film

$6

$4

D0270

Bitewing - single film

$9

$6

D0272

Bitewings - two films

$14

$9

D0274

Bitewing - four films

$19

$12

D0277

Bitewing - vertical

$12

$7

D0330

Panoramic film

$36

$23

Tests and Laboratory Exams

D0460

Pulp vitality tests

$11

$7

Palliative Treatment

D9110

Palliative (emergency) treatment of dental pain - minor procedure

$24

$15

D2940

Sedative filling

$24

$15

Preventive

D1110

Prophylaxis - adult*

-

$16

D1120

Prophylaxis - child*

$22

$14

D1203

Topical application of fluoride (prophylaxis not included) - child

$13

$8

D1204

Topical application of fluoride (prophylaxis not included) - adult

-

$8

* Limited to two per person per calendar year

Space Maintenance (passive appliances)

D1510

Space maintainer - fixed - unilateral

$94

$59

D1515

Space maintainer - fixed - bilateral

$139

$87

D1520

Space maintainer - removable - unilateral

$94

$59

D1525

Space maintainer - removable - bilateral

$139

$87

D1550

Recementation of space maintainer

$22

$14

Amalgam Restorations (including polishing)

D2140

Amalgam - one surface, primary or permanent

$25

$16

D2150

Amalgam - two surfaces, primary or permanent

$37

$23

D2160

Amalgam - three surfaces, primary or permanent

$50

$31

D2161

Amalgam - four or more surfaces, primary or permanent

$56

$35

Filled or Unfilled Resin Restorations

D2330

Resin - one surface, anterior

$25

$16

D2331

Resin - two surfaces, anterior

$37

$23

D2332

Resin - three surfaces, anterior

$50

$31

D2335

Resin - four or more surfaces or involving incisal angle (anterior)

$56

$35

D2391

Resin-based composite - one surface, posterior

$25

$16

D2392

Resin-based composite - two surfaces, posterior

$37

$23

D2393

Resin-based composite - three surfaces, posterior

$50

$31

D2394

Resin-based composite - four or more surfaces, posterior

$50

$31

Inlay Restorations

D2510

Inlay - metallic - one surface

$25

$16

D2520

Inlay - metallic - two surfaces

$37

$23

D2530

Inlay - metallic - three or more surfaces

$50

$31

D2610

Inlay - porcelain/ceramic - one surface

$25

$16

D2620

Inlay - porcelain/ceramic - two surfaces

$37

$23

D2630

Inlay - porcelain/ceramic - three or more surfaces

$50

$31

D2650

Inlay - composite/resin - one surface

$25

$16

D2651

Inlay - composite/resin - two surfaces

$37

$23

D2652

Inlay - composite/resin - three or more surfaces

$50

$31

Other Restorative Services

D2951

Pin retention - per tooth, in addition to restoration

$13

$8

Extractions - includes local anesthesia and routine post-operative care

D7140

Extraction, erupted tooth or exposed root

$30

$19

D7210

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

$43

$27

D7250

Surgical removal of residual tooth roots (cutting procedure)

$71

$45

D9220

General anesthesia in connection with covered extractions

$43

$27

1 Your FEHBP may cover this amount.

This dental product, offered by BCBSNC, is intended to complement the policy offered to federal employees and retirees by the federal government. This dental product is not approved, endorsed or accredited by the federal government, and it is in no way connected to the federal government or to the U.S. Office of Personnel Management.