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SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS |
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| D1000-D1999 II. Preventive - 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 |
| D1110 |
Prophylaxis cleaning - adult - 1 per 6 month period |
$ 20 |
| D1330 |
Oral hygiene instructions |
No Cost |
| D1510 |
Space maintainer - fixed - unilateral |
$100 |
| D1515 |
Space maintainer - fixed - bilateral |
$150 |
| D1520 |
Space maintainer - removable - unilateral |
$100 |
| D1525 |
Space maintainer - removable - bilateral |
$150 |
| D1550 |
Re-cementation of space maintainer |
$ 10 |
| D1555 |
Removal of fixed space maintainer |
$ 10 |
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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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