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	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

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

Code	Description	Enrollee Pays
D1110	Prophylaxis cleaning - adult - 1 per 6 month period	$ 25
D1120	Prophylaxis cleaning - child - 1 per 6 month period	$ 25
D1203	Topical application of fluoride (prophylaxis not included) - child - to age 19; 1 per 6 month period	$ 20
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients - child - to age 19; 1 per 6 month period	$ 20
D1330	Oral hygiene instructions	No Cost
D1351	Sealant - per tooth - limited to permanent molars through age 15	$ 15
D1510	Space maintainer - fixed - unilateral	$100
D1515	Space maintainer - fixed - bilateral	$140
D1520	Space maintainer - removable - unilateral	$100
D1525	Space maintainer - removable - bilateral	$140
D1550	Re-cementation of space maintainer	$ 10
D1555	Removal of fixed space maintainer	$ 10

* 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.