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Advantage AVF-1 Schedule of Benefits

Diagnostic Schedule

Limitations and Exclusions

ADA
CODE
Procedure Member
Pays
D0120   PERIODIC ORAL EVALUATION (limit 2 every 12 months)   No Charge
D0140   LIMITED ORAL EVALUATION-PROBLEM FOCUSED   No Charge
D0150   COMPREHENSIVE ORAL EVALUATION (new or existing patient)   No Charge
D0160   DETAIL AND EXTENSIVE ORAL EVALUATION   No Charge
D0170   RE-EVALUATION - LIMITED, PROBLEM FOCUSED (existing patient)   No Charge
D0180   COMPREHENSIVE PERIODONTAL EVALUATION (new or existing patient)   No Charge

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%.

 



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