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SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS |
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| D9000-D9999 XI. Adjunctive General Services - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * |
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| Code |
Description |
Enrollee Pays |
| D9110 |
Palliative (emergency) treatment of dental pain - minor procedure |
$ 35 |
| D9211 |
Regional block anesthesia |
No Cost |
| D9212 |
Trigeminal division block anesthesia |
No Cost |
| D9215 |
Local anesthesia |
No Cost |
| D9310 |
Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician |
$ 35 |
| D9430 |
Office visit for observation (during regularly scheduled hours) - no other services performed |
$ 5 |
| D9440 |
Office visit - after regularly scheduled hours |
$ 50 |
| D9450 |
Case presentation, detailed and extensive treatment planning |
No Cost |
| D9999 |
Unspecified adjunctive procedure, by report- includes failed appointment without 24 hour notice - per 15 minutes of appointment time |
$ 15 |
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| * If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed, referable procedures that are not available in the contract facility or that require a Dentist to provide specialized services may be provided by a contracted oral surgeon, endodontist, or periodontist at 75 percent of the Contract Specialist's "filed fees." Specialist services are only available in areas where there is a DeltaCare USA Contract Specialist, and upon referral by the assigned Contract Dentist. |
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