Schedule of Benefits for Direct Referral Dental Plan

Customer Service (800) 880-1800 GCERT2010-DHMO-SOB sob Page 1 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Schedule of Benefits Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* SGX100-CA This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions and Limitations. During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. Missed Appointments: If you need to cancel or reschedule an appointment, you should notify the dental office as far in advance as possible. This will allow the dental office to accommodate another person in need of attention. *Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation to SafeGuard for any necessary referral. Code Service Co-payment Diagnostic Treatment D0120 Periodic oral evaluation - established patient. An evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. The findings are discussed with the patient. Report additional diagnostic procedures separately. $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 D0150 Comprehensive oral evaluation - new or established patient $0 D0160 Detailed and extensive oral evaluation - problem focused, by report $0 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $0 D0171 Re-evaluation – post-operative office visit $0 D0180 Comprehensive periodontal evaluation - new or established patient. This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history, and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, and occlusal relationships. $0 • Office visit - per visit (including all fees for sterilization and/or infection control) $5 Radiographs/Diagnostic Imaging (X-rays) D0210 A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all. $0 D0220 Intraoral – periapical first radiographic image $0 D0230 Intraoral – periapical each additional radiographic image $0 D0240 Intraoral – occlusal radiographic image $0 D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector $0 D0270 Bitewing – single radiographic image $0 D0272 Bitewings – two radiographic images $0