Advantage AVF-1 Schedule of Benefits

Periodontics (Gum Treatment) Schedule

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

ADA CODE		Procedure		Member Pays
D4210		GINGIVECTOMY/GINGIVOPLASTY-4+ CONTIGUOUS TEETH, PER QUADRANT (limit 1 every 12 months)		$278
D4211		GINGIVECTOMY/GINGIVOPLASTY-1 TO 3 TEETH, PER QUADRANT (limit 1 every 12 months)		$119
D4240		GINGIVAL FLAP PROC INCLUDING ROOT PLANING, 4+ CONTIGUOUS TEETH, PER QUADRANT (limit 1 every 12 months)		$328
D4241		GINGIVAL FLAP PROC INCLUDING ROOT PLANING, 1 TO 3 TEETH, PER QUAD (limit 1 every 12 months)		$169
D4249		CROWN LENGTHENING-HARD TISSUE		$374
D4260		OSSEOUS SURGERY INCLUDING FLAP ENT/CLOS, 4+ CONTIGUOUS TEETH, PER QUAD		$529
D4261		OSSEOUS SURGERY INCLUDING FLAP ENT/CLOS, 1 TO 3 TEETH, PER QUADRANT		$275
D4341		PERIODONTAL SCALING/ROOT PLANING, 4+ CONTIGUOUS TEETH, PER QUADRANT (limit 2 per quad every 12 months)		$33
D4342		PERIODONTAL SCALING/ROOT PLANING, 1 TO 3 TEETH, PER QUADRANT (limit 2 per quad every 12 months)		$18
D4355		FULL MOUTH DEBRIDEMENT TO ENABLE COMP EVALUATION & DIAGNOSTIC		$22
D4910		PERIODONTAL MAINTENANCE (limit 2 every 12 months)		$20

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%.