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MetLeife SCHEDULE OF BENEFITS <br />Benefits provided by SafeGuard Health Plans, Inc., a MetLife company <br />Direct Referral Dental Plan* 0041-D <br />This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co- <br />payments associated with each service. There are other factors that impact how your plan works and those <br />are Included here in the Exclusions & Limitations. We have also added some dental terminology definitions to <br />help you better understand your plan - these can be found at the back of this Schedule. <br />During the course of treatment, your SafeGuard selected general dentist may recommend the services of a <br />dental specialist. <br />'Your SafeGuard selected general dentist is responsible for coordinating your dental care, and If necessary, <br />referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard <br />for any necessary referral. <br />Your and Your <br />Dependent's <br />Code <br />Service <br />uo-vayr <br />Diagnostic Treatment <br />D0120 <br />Periodic oral evaluation - established patient <br />$0 <br />D0140 <br />Limited oral evaluation - problem focused <br />$0 <br />D0145 <br />Oral evaluation for a patient under three years of age and counseling with <br />$0 <br />primary caregiver <br />D0150 <br />Comprehensive oral evaluation - new or established patient <br />$0 <br />D0171 <br />Re-evaluation — post-operative office visit <br />$0 <br />D0180 <br />Comprehensive periodontal evaluation - new or established patient <br />$0 <br />Office visit — per visit (including all fees for sterilization and/or infection control <br />$0 <br />Radiographs / Diagnostic Imaging (X-rays) <br />$0 <br />D0210 <br />Intraoral — complete series of radiographic Images <br />$0 <br />D0220 <br />Intraoral — periapical first radiographic image <br />$0 <br />D0230 <br />Intraoral — periapical each additional radiographic image <br />$0 <br />D0240 <br />Intraoral — occlusal radiographic Image <br />$0 <br />D0250 <br />Extraoral —first radiographic image <br />$0 <br />D0260 <br />Extraoral — each additional radiographic image <br />$0 <br />D0270 <br />Bitewing — single radiographic image <br />$0 <br />D0272 <br />Bitewings — two radiographic images <br />$0 <br />D0273 <br />Bitewings — three radiographic Images <br />$0 <br />D0274 <br />Bitewings — four radiographic images <br />$0 <br />D0330 <br />Panoramic radiographic image <br />$0 <br />D0350 <br />2D oral/facial photographic image obtained intra -orally or extra -orally <br />$0 <br />Tests and Examinations <br />D0460 <br />Pulp vitality tests <br />$0 <br />D0470 <br />Diagnostic casts <br />$0 <br />0041 -D -SOB <br />25C-40 <br />1 <br />01/15 <br />