Advantage AVF-1 Schedule of Benefits

Diagnostic X-Rays and Tests Preventive Care Restorative Services (Fillings) Other Restorative Services Crowns and Bridges

Endodontics Periodontics (Gum Treatment) Prosthetics (Dentures) Extractions & Oral Surgery Orthodontics (Adults or Children) Miscellaneous Services

Limitations and Exclusions

Note:
All procedures listed might not be performed by the Participating General Dentist you select. The co-payments shown apply to those Participating General Dentists who do perform those services. Therefore, you are encouraged to discuss the availability of the scheduled services with your Participating General Dentist. Procedures not listed on this schedule of benefits, that are performed by the Participating General Dentist, will be charged at that Participating General Dentist's usual and customary fee less 20%.

Specialist Services
Should you need a specialist (i.e. Endodontist, Oral Surgeon, Orthodontist, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Co-payment percentage amounts are applicable when treatment is performed by a Participating Specialist. Procedures not listed on this schedule of benefits, that are performed by a Participating Specialist, will be charged at that Participating Specialist's usual and customary fee less 20%.