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D7971 Excision of pericoronal gingiva $85 <br />Orthognathic surgery for treatment of congenital anomalies for enrolled 75% of charges <br />Children under age 19 - Subject to a lifetime benefit maximum of $3 000 <br />9. Adjunctive General Services <br />D9110 Palliative (emergency) treatment of dental pain - minor procedure <br />D9120 Fixed partial denture sectioning <br />D9222 & D9223 Deep sedation/general anesthesia <br />D9230 Inhalation of nitrous oxide/analgesia, anxiolysis <br />D9310 <br />D9420 <br />D9430 <br />D9440 <br />D9910 <br />D9911 <br />D9951 <br />D9970 <br />$0 <br />$0 <br />First 30 Minutes: $250 <br />Each Additional 15 Minutes: $0 <br />$40 <br />Consultation - diagnostic service provided by dentist or physician other than requesting <br />dentist or physician <br />Hospital or ambulatory surgical center call <br />Office visit for observation (during regularly scheduled hours) - no other services <br />performed <br />Office visit - after regularly scheduled hours <br />Application of desensitizing medicament <br />Application of desensitizing resin for cervical and/or root surface, per tooth <br />Occlusal adjustment - limited <br />Enamel microabrasion <br />Out of Area Emergency Reimbursement <br />(The Enrollee is reimbursed up to $100 per visit.) <br />All charges in excess <br />Current Dental Terminology (CDT) 0 2020 American Dental Association. <br />All rights reserved. <br />$0 <br />$125 <br />so <br />$20 <br />$0 <br />$0 <br />$0 <br />$0 <br />of $100 <br />001 L-WA811(5/20) <br />28 <br />