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Advantage AVF-1 Schedule of Benefits
Preventive Care Schedule
Limitations and Exclusions
ADA
CODE |
|
Procedure |
|
Member
Pays |
 |
|
|
|
|
| D1110 |
|
PROPHYLAXIS-ADULT (limit 1 every 6 months) |
|
No Charge |
| D1120 |
|
PROPHYLAXIS-CHILD (limit 1 every 6 months) |
|
No Charge |
| D1201 |
|
TOPICAL APPLICATION FLUORIDE INCLUDING
PROPHYLAXIS-CHILD
(limit 2 every 12 months for child age 16 years and younger) |
|
No Charge |
| D1203 |
|
TOPICAL APPLICATION FLUORIDE EXCL
PROPHYLAXIS-CHILD
(limit 2 every 12 months for child age 16 years and younger) |
|
No Charge |
| D1351 |
|
SEALANT-PER TOOTH
(limit 1 per tooth every 12
months for child age 13 years and younger) |
|
No Charge |
| D1510 |
|
SPACE MAINTAINER-FIXED UNILATERAL |
|
$137 |
| D1515 |
|
SPACE MAINTAINER-FIXED BILATERAL |
|
$180 |
| D1520 |
|
SPACE MAINTAINER-REMOVABLE UNILATERAL |
|
$170 |
| D1525 |
|
SPACE MAINTAINER-REMOVABLE BILATERAL |
|
$232 |
| D1550 |
|
RECEMENTATION OF SPACE MAINTAINER |
|
$12 |
|
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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