My Benefits



	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement Coverage Continuation Description of Benefits and Copayments (Schedule A) Limitations and Exclusions (Schedule B)

SCHEDULE OF BENEFITS AND COPAYMENTS

D9000-D9999 XII. Adjunctive General Services - When referable services are provided by a Contract Specialty Care Dentist, the Enrollee pays 75 percent of that Dentist's "filed fees." *

Code	Description	Enrollee Pays
D9110	Palliative (emergency) treatment of dental pain - minor procedure	$ 20
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	$ 25
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

*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, periodontist or pediatric dentist at 75 percent of the Contract Specialty Care Dentist's "filed fees." Specialized Services are only available upon referral by the assigned Contract Dentist.