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Advantage AVF-1 Schedule of Benefits
Miscellaneous Services Schedule
Limitations and Exclusions
ADA
CODE |
|
Procedure |
|
Member
Pays |
 |
|
|
|
|
| D9110 |
|
PALLIATIVE (EMERGENCY) TREATMENT |
|
$34 |
| D9215 |
|
LOCAL ANESTHESIA |
|
$11 |
| D9241 |
|
IV CONSCIOUS SEDATION - FIRST 30 MINUTES |
|
$111 |
| D9242 |
|
IV CONSCIOUS SEDATION - EACH ADDITIONAL 15 MINUTES |
|
$47 |
| D9310 |
|
CONSULTATION DIAGNOSTIC SERVICE NON - TREATING PRACT |
|
No Charge |
| D9951 |
|
OCCLUSAL ADJUSTMENT - LIMITED |
|
$45 |
| D9952 |
|
OCCLUSAL ADJUSTMENT - COMPLETE |
|
$251 |
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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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