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| SCHEDULE OF BENEFITS AND COPAYMENTS |
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| D8000-D8999 XI. Orthodontics 10 |
| ** If Copayment dollar amount is not listed, Enrollee pays 75 percents of the Contact Orthodontist's "filed fees." |
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| Code |
Description |
Enrollee Pays |
| D8070 |
Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 |
** |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19 |
** |
| D8090 |
Comprehensive orthodontic treatment of the adult dentition - adults, including dependent adult children from age 19 to 25 |
** |
| D8660 |
Pre-orthodontic treatment visit - not to be charged with any other consultation procedure(s) |
No Cost |
| D8680 |
Orthodontic retention (removal of appliances, construction andplacement of retainers) |
** |
| D8999 |
Unspecified orthodontic procedure, by report - includes START-UP FEES (including initial examination, diagnosis, consultation and initial banding) 12 |
$ 200 |
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