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

D1000-D1999 II. Preventive - When referable services are provided by a Contract Specialty Care Dentist, the Enrollee pays 75 percent of that Dentist's "filed fees." * ¹

Code	Description	Enrollee Pays
D1110	Prophylaxis cleaning - adult - 1 per 6 month period ¹	$ 15
D1120	Prophylaxis cleaning - child - 1 per 6 month period	$ 15
D1203	Topical application of fluoride (prophylaxis not included) - child - 1 per 6 month period ¹	No Cost
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients – child to age 19; 1 per 6 month period	No Cost
D1330	Oral hygiene instructions	No Cost
D1351	Sealant - per tooth - through age 15	$ 10
D1510	Space maintainer - fixed - unilateral	$ 100
D1515	Space maintainer - fixed - bilateral	$ 125
D1520	Space maintainer - removable - unilateral	$ 100
D1525	Space maintainer - removable - bilateral	$ 125
D1550	Re-cementation of space maintainer	$ 10
D1555	Removal of fixed space maintainer	$ 20

*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.