My Benefits



	Benefits summary Emergency Services Specialist services Benefits, limitations and exclusions Description of benefits and copayments (Schedule A) Limitations of benefits (Schedule B) Benefits that are not covered (Schedule B)

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

D4000-D4999 V. Periodontics

Includes preoperative and postoperative evaluations and treatment under a local anesthetic.

Code	Description	Enrollee Pays
D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant	$260
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant	$ 50
D4240	Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant	$300
D4241	Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant	$300
D4260	Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant	$450
D4261	Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant	$450
D4341	Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months	$ 60
D4342	Periodontal scaling and root planing, one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months	$ 60
D4355	Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months	$ 60
D4910	Periodontal maintenance - limited to 1 treatment each 6 month period	$ 45

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