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Advantage AVF-1 Schedule of Benefits
Extractions & Oral Surgery Schedule
Limitations and Exclusions
ADA
CODE |
|
Procedure |
|
Member
Pays |
 |
|
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| D7111 |
|
CORONAL REMNANTS-DECIDUOUS TEETH |
|
$43 |
| D7140 |
|
EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEV/FORC) |
|
$58 |
| D7210 |
|
SURGICAL REMOVAL OF ERUPTED TOOTH |
|
$91 |
| D7220 |
|
REMOVAL IMPACTED TOOTH-SOFT TISSUE |
|
$114 |
| D7230 |
|
REMOVAL IMPACTED TOOTH-PARTIAL BONY |
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$151 |
| D7240 |
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REMOVAL IMPACTED TOOTH-COMPLETE BONY |
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$177 |
| D7241 |
|
REMOVAL IMPACTED TOOTH-UNUSUAL COMPLICATIONS |
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$223 |
| D7250 |
|
SURGICAL REMOVAL RESIDUAL TOOTH ROOTS-CUTTING PROC |
|
$96 |
| D7310 |
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ALVEOLOPLASTY IN CONJ WITH EXTRACTION-PER QUAD |
|
$106 |
| D7320 |
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ALVEOLOPLASTY NOT IN CONJ WITH EXTRACTION-PER QUAD |
|
$471 |
| D7510 |
|
INCISION & DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE |
|
$101 |
| D7520 |
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INCISION & DRAINAGE OF ABSCESS-EXTRAORAL SOFT TISSUE |
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$480 |
| D7960 |
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FRENULECTOMY-SEPARATE PROCEDURE |
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$222 |
| D7970 |
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EXCISION OF HYPERPLASTIC TISSUE-PER ARCH |
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$229 |
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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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