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Advantage AVF-1 Schedule of Benefits

Orthodontics Schedule

Limitations and Exclusions

ADA
CODE
Procedure Member
Pays
D8070/
D8080
Comprehensive Orthodontic Treatment of the transitional/adolescent dentition  
  Children up to 19 years of age  
  Up to 24 months of routine orthodontic treatment for Class I and Class II cases  
  Consultation No Charge
  Evaluation $35.00
  Records/Treatment Planning $250
  Orthodontic Treatment $2,100
 
D8090 Comprehensive Orthodontic Treatment of the adult dentition  
  Adults 19 years of age and over  
  Up to 24 months of routine orthodontic treatment for Class I and Class II cases  
  Consultation No Charge
  Evaluation $35.00
  Records/Treatment Planning $250
  Orthodontic Treatment $2,300
D8680 Retention $450

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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