My Benefits



	Emergency Services Specialist Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Extension of Benefits Conversion Entire Contract Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

Oral and Maxillofacial Surgery - When referable services are provided by a Contract Specialist, 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	$ 40
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	$ 40
D7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth	$ 70
D7220	Removal of impacted tooth - soft tissue	$ 95
D7230	Removal of impacted tooth - partially bony	$190
D7240	Removal of impacted tooth - completely bony	$210
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	$230
D7250	Surgical removal of residual tooth roots (cutting procedure)	$ 75
D7286	Biopsy of oral tissue - soft - does not include pathology laboratory procedures	$100
D7310	Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$150
D7311	Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant	$150
D7320	Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$200
D7321	Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	$200
D7471	Removal of lateral exostosis (maxilla or mandible)	$150
D7510	Incision and drainage of abscess - intraoral soft tissue	$35
D7960	Frenulectomy (frenectomy or frenotomy) - separate procedure	$160

* 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 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.