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SCHEDULE OF BENEFITS (Continued) <br />0041 -D -SOB <br />25C-45 <br />Your and Your <br />Dependent's <br />Code <br />Service <br />Co -Payment <br />Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not <br />covered. <br />D7140 <br />Extraction, erupted tooth or exposed root (elevation and/or forceps removal) <br />$0 <br />D7210 <br />Surgical removal of erupted tooth requiring removal of bone and/or sectioning <br />$0 <br />of tooth and including elevation of mucoperiosteal flap if indicated <br />D7220 <br />Removal of Impacted tooth — soft tissue <br />$0 <br />D7230 <br />Removal of impacted tooth — partially bony <br />$0 <br />D7240 <br />Removal of impacted tooth — completely bony <br />$0 <br />D7250 <br />Surgical removal of residual tooth roots (cutting procedure) <br />$0 <br />D7285 <br />Inclsional biopsy of oral tissue — hard (bone, tooth) <br />$0 <br />D7286 <br />Incisional biopsy of oral tissue — soft <br />$0 <br />157310 <br />Alveoloplasty In conjunction with extractions — four or more teeth or tooth <br />$0 <br />spaces, per quadrant <br />D7311 <br />Alveoloplasty in conjunction with extractions — one to three teeth or tooth <br />$0 <br />spaces, per quadrant <br />D7320 <br />Alveoloplasty not in conjunction with extractions — four or more teeth or tooth <br />$0 <br />spaces, per quadrant <br />D7321 <br />Alveoloplasty not in conjunction with extractions — one to three teeth or tooth <br />$0 <br />spaces, per quadrant <br />D7960 <br />Frenulectomy — aka frenectomy or frenotomy— separate procedure not <br />Incidental to another procedure <br />$0 <br />D7903 <br />Frenuloplasty <br />$0 <br />Orthodontics <br />D8020 <br />Limited orthodontic treatment of the transitional dentition <br />(up to 24 months) <br />$500 <br />D8030 <br />Limited orthodontic treatment of the adolescent dentition <br />(up to 24 months) <br />$500 <br />D8040 <br />Limited orthodontic treatment of the adult dentition (up to 24 months) <br />$500 <br />D8070 <br />Comprehensive orthodontic treatment of the transitional dentition (full <br />treatment case up to 24 months - including fixed/removable appliances) <br />$1,000 <br />D8080 <br />Comprehensive orthodontic treatment of the adolescent dentition (full <br />treatment case up to 24 months - including fixed/removable appliances) <br />$1,000 <br />D8090 <br />Comprehensive orthodontic treatment of the adult dentition (full <br />treatment case up to 24 months - including fixed/removable appliances) <br />$1,000 <br />D8660 <br />Pre -orthodontic treatment examination to monitor growth and development <br />$25 <br />D8680 <br />Orthodontic retention (removal of appliances, construction and placement of <br />retainer(s)) <br />$250 <br />D8693 <br />Re -cement or re -bond fixed retainers <br />$0 <br />Adjunctive General Services <br />D9110 <br />Palliative (emergency) treatment of dental pain — minor procedure <br />$0 <br />D9120 <br />Fixed partial denture sectioning <br />$0 <br />D9215 <br />Local anesthesia In conjunction with operative or surgical procedures <br />$0 <br />D9219 <br />Evaluation for deep sedation or general anesthesia <br />$0 <br />D9310 <br />Consultation — diagnostic service provided by dentist or physician other than <br />requesting dentist or physician <br />$0 <br />0041 -D -SOB <br />25C-45 <br />