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

D7000-D7999 X. Oral and Maxillofacial Surgery - When referable services are provided by a Contract Specialty Care Dentist, the Enrollee pays 75 percent of that Dentist's "filed fees." *

Includes preoperative and postoperative evaluations and treatment under local anesthetic.

Code	Description	Enrollee Pays
D7111	Extraction, coronal remnants - deciduous tooth	$ 25
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	$ 35
D7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth	$ 40
D7220	Removal of impacted tooth - soft tissue	$ 65
D7230	Removal of impacted tooth - partially bony	$ 90
D7240	Removal of impacted tooth - completely bony	$ 140
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	$ 155
D7250	Surgical removal of residual tooth roots (cutting procedure)	$ 35
D7286	Biopsy of oral tissue - soft - does not include pathology laboratory procedures	$ 45
D7310	Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$ 90
D7311	Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant	$ 90
D7320	Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$ 120
D7321	Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant	$ 120
D7471	Removal of lateral exostosis (maxilla or mandible)	$ 90
D7510	Incision and drainage of abscess - intraoral soft tissue	$ 35
D7960	Frenulectomy (frenectomy or frenotomy) - separate procedure	$ 65

*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.