Plan Information

Features

Our Dental SelectHMO plan offers comprehensive coverage that is designed to fit your family’s budget.  Services must be performed by an Anthem Blue Cross Dental SelectHMO participating dentist in order to be covered.  Benefits are immediately available for most services and you won’t have to meet any deductibles.

Each time you visit a  participating dentist, you’ll pay a low $5 office visit fee and a set copayment for some procedures. Once you pay the $5 office visit fee, most diagnostic and preventive services (such as cleanings, exams, and X-rays) are covered in full.

Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM® is a registered trademark. The Blue Cross® name and symbol are registered marks of the Blue Cross Association.

* You must meet a 6 month waiting period before these benefits are payable.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $0
D0140 limited oral evaluation - problem focused $0
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver $0
D0150 comprehensive oral evaluation - new or established patient $0
D0160 detailed and extensive oral evaluation - problem focused, by report $0
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $0
D0180 comprehensive periodontal evaluation - new or established patient $0
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $0
D0220 intraoral - periapical first film $0
D0230 intraoral - periapical each additional film $0
D0240 intraoral - occlusal film $0
D0250 extraoral - first film $0
D0260 extraoral - each additional film $0
D0270 bitewing - single film $0
D0272 bitewings - two films $0
D0273 bitewings - three films $0
D0274 bitewings - four films $0
D0330 panoramic film $0
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $5
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $0
D1120 prophylaxis - child $0
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child $0
Other Preventive Services You Pay
D1351 sealant - per tooth $25
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $145
D1515 space maintainer - fixed - bilateral $212
D1520 space maintainer - removable - unilateral $195
D1525 space maintainer - removable - bilateral $231
D1550 re-cementation of space maintainer $26
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $0*
D2150 amalgam - two surfaces, primary or permanent $0*
D2160 amalgam - three surfaces, primary or permanent $0*
D2161 amalgam - four or more surfaces, primary or permanent $0*
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $0*
D2331 resin-based composite - two surfaces, anterior $0*
D2332 resin-based composite - three surfaces, anterior $0*
D2391 resin-based composite - one surface, posterior $75
D2392 resin-based composite - two surfaces, posterior $102
D2393 resin-based composite - three surfaces, posterior $124
Inlay/Onlay Restorations You Pay
D2520 inlay - metallic - two surfaces $349
D2530 inlay - metallic - three or more surfaces $388
Crowns - Single Restorations Only You Pay
D2720 crown - resin with high noble metal $417
D2722 crown - resin with noble metal $365
D2750 crown - porcelain fused to high noble metal $432
D2751 crown - porcelain fused to predominantly base metal $432
D2752 crown - porcelain fused to noble metal $432
D2782 crown - 3/4 cast noble metal $473
D2790 crown - full cast high noble metal $432
D2791 crown - full cast predominantly base metal $432
D2792 crown - full cast noble metal $432
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $42
D2920 re-cement crown $44
D2930 prefabricated stainless steel crown - primary tooth $106
D2951 pin retention - per tooth, in addition to restoration $31
D2954 prefabricated post and core in addition to crown $121
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $32
D3120 pulp cap - indirect (excluding final restoration) $41
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $62
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $289
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $341
D3330 endodontic therapy, molar (excluding final restoration) $459
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $289
D3347 retreatment of previous root canal therapy - bicuspid $341
D3348 retreatment of previous root canal therapy - molar $459
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $520
Non-Surgical Periodontal Service You Pay
D4342 periodontal scaling and root planing - one to three teeth per quadrant $101*
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $577
D5120 complete denture - mandibular $577
D5130 immediate denture - maxillary $585
D5140 immediate denture - mandibular $540
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $430
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $430
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $430
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $430
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $31
D5411 adjust complete dentures - mandibular $31
D5421 adjust partial denture - maxillary $31
D5422 adjust partial denture - mandibular $31
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $70
Repairs to Partial Dentures You Pay
D5630 repair or replace broken clasp $77
D5640 replace broken teeth - per tooth $57
D5650 add tooth to existing partial denture $75
D5660 add clasp to existing partial denture $75
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $127
D5711 rebase complete mandibular denture $127
D5720 rebase maxillary partial denture $142
D5721 rebase mandibular partial denture $142
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $103
D5731 reline complete mandibular denture (chairside) $103
D5740 reline maxillary partial denture (chairside) $92
D5741 reline mandibular partial denture (chairside) $92
D5750 reline complete maxillary denture (laboratory) $176
D5751 reline complete mandibular denture (laboratory) $176
D5760 reline maxillary partial denture (laboratory) $176
D5761 reline mandibular partial denture (laboratory) $176
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $432
D6211 pontic - cast predominantly base metal $412
D6212 pontic - cast noble metal $432
D6240 pontic - porcelain fused to high noble metal $432
D6241 pontic - porcelain fused to predominantly base metal $432
D6242 pontic - porcelain fused to noble metal $432
D6250 pontic - resin with high noble metal $432
D6251 pontic - resin with predominantly base metal $432
D6252 pontic - resin with noble metal $432
Fixed Partial Denture Retainers-Crowns You Pay
D6740 crown - porcelain/ceramic $490
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $56
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $73
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care You Pay
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $113
D7220 removal of impacted tooth - soft tissue $136
D7230 removal of impacted tooth - partially bony $176
D7240 removal of impacted tooth - completely bony $200
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $223
Orthodontics
Comprehensive Orthodontic Treatment You Pay
D8080 comprehensive orthodontic treatment of the adolescent dentition $2870
D8090 comprehensive orthodontic treatment of the adult dentition $3045

* You must meet a 6 month waiting period before these benefits are payable.