2510
2520
2530
2543
2544
2610
2620
2630
2643
2644
2710
2740
2750
2751
2752
2790
2791
2792
2810
2910
2920
2930
2931
2940
2950
2951
2952
2954

Inlay, metal, 1 surface
Inlay, metal, 2 surface
Inlay, metal, 3 surface
Inlay/Onlay, metal, 3 surfaces
Inlay/Onlay, metal, 4+ surfaces
Inlay, porcelain, 1 surface
Inlay, porcelain, 2 surface
Inlay, porcelain, 3+ surfaces
Inlay/Onlay, porcelain, 3 surface
Inlay/Onlay, porcelain, 4+ surfaces
Crown, All Resin (lab)
Crown, all porcelain/ceramic
Crown, porcelain, high noble
Crown, porcelain, base
Crown, porcelain, noble
Crown, full cast, high noble
Crown, full cast, base
Crown, full cast, noble
Crown, 3/4 cast
Recement inlay/onlay
Recement crown
Crown/prefab/SS/primary
Crown/prefab/SS/perm
Sedative Filling
Core (crown) build-up (inc pins)
Pin retention (per tooth)
Cast post & core
Prefabricated post & core

7110
7120
7130
7210
7220
7230
7240
7250
7280
7281
7310
7320
7470
7510
7880
7960
7970

Simple extraction per tooth
Simple extraction each add'l tooth
Root removal/exposed root
Surgical extraction/erupted
Surgical extraction/soft tissue impaction
Surgical extraction/partial bony impaction
Surgical extraction/full bony impaction
Surgical root removal
Surgical exposure/unerupted/ortho
Surgical exposure/uneruption/aid eruption
Alveoloplasty with extractions
Alveoloplasty without extractions
Removal of exostosis
Incision & drain
Occlusal/orthotic/TMJ device
Frenectomy
Excision of hyperplastic tissue

BRIDGES COVERAGE (per tooth/unit) (type IV)

MISCELLANEOUS COVERAGE (type X)

6210
6211
6212
6240
6241
6242
6520
6530
6544
6545
6750
6751
6752
6780
6790
6791
6792
6930
6950
6970
6972
6973
6975

FPD pontic/cast/high noble
FPD pontic/cast/base
FPD pontic/cast/noble
FPD pontic/porcelain/high noble
FPD pontic/porcelain/base
FPD pontic/porcelain/noble
FPD retainer/inlay/2 surface
FPD retainer/inlay/3 surface
FPD retainer/onlay/4 surfaces
FPD retainer/resin bonded FPD wing
FPD retainer/porcelain/high noble
FPD retainer/porcelain/base
FPD retainer/porcelain/noble
FPD retainer, 3/4 crown, high noble
FPD retainer/cast/high noble
FPD retainer/cast/base
FPD retainer/cast/noble
Recement FPD
Precision attachment
FPD cast post & core
FPD prefabricated post & core
FPD crown build up (inc pins)
FPD cast copping

0460
0470
0471
1330
1510
1515
1520
1525
1550
9110
9215
9220
9221
9230
9240
9440
9951
9952

Pulp vitality test
Study cast
Photographs
Oral Hygiene Instructions
Space maintainer (fix/uni)
Space maintainer (fix/bilat)
Space maintainer (removable/uni)
Space maintainer (removable/bilat)
Recement space maintainer
Palliative emergency treatment
Local anesthesia/not in conj with a proc.
General anesthesia/first 30 min
General anesthesia/each add'l 30 min
Analgesia
Intravenous sedation
Emergency exam (after regular office hours)
Occlusal adjustment/limited
Occlusal adjustment/complete

COSMETIC COVERAGE (type V)

2960
2961
2962
3961

Veneer, resin, chairside
Veneer, resin, lab
Veneer, porcelain, lab
In Office Whitening

DENTURE & PARTIAL COVERAGE (type VI)

EXCLUSIONS & LIMITATIONS SUMMARY

5110
5120
5130
5140
5211
5212
5213
5214
5281
5410
5411
5421
5422
5510
5520
5610
5620
5630
5640
5650
5660
5710
5711
5720
5721
5730
5731
5740
5741
5750
5751
5760
5761
5810
5811
5820
5821
5850
5851

Complete upper denture
Complete lower denture
Complete immediate upper denture
Complete immediate lower denture
Partial denture, up/acrylic
Partial denture, low/acrylic
Partial denture, up/metal
Partial denture, low/metal
Unilateral partial/removable
Up denture adjustment
Low denture adjustment
Up partial adjustment
Low partial adjustment
Repair full denture base
Replace missing tooth/CD
Repair partial/resin base
Repair partial framework
Repair/replace partial clasp
Replace tooth on partial
Add tooth to partial
Add clasp to partial
Rebase upper denture
Rebase lower denture
Rebase upper partial
Rebase low partial
Reline upper denture (office)
Reline lower denture (office)
Reline upper partial (office)
Reline lower partial (office)
Reline upper denture (lab)
Reline lower denture (lab)
Reline upper partial (lab)
Reline lower partial (lab)
Interim upper denture
Interim lower denture
Interim upper partial
Interim lower partial
Tissue conditioning (upper)
Tissue conditioning (lower)

1.   Services for injuries or conditions which are not covered under Workman's Compensation or other form of insurance or program.
2.   Services which, in the opinion of the dentist, are not necessary for the plan member's dental health.
3.   Any service or services not listed within the "Member Schedule of Services & Copayments".
4.   Hospitalization for any dental procedure.
5.   Cosmetic, elective, or esthetic dentistry, unless listed herein.
6.   Limit of one (1) cleaning per every six (6) months (2/year).
7.   Limit of four (4) exams or consults of any type per plan year.
8.   Limit of four (4) x-rays of any type per plan year.
9.   Limit of one (1) panoramic or similar x-ray every three (3) years.
10. Limit of one (1) crown per tooth every seven (7) years.
11. Limit of one full mouth x-rays every three (3) years.
12. Routine cleaning does not apply to patients with periodontal disease.
13. DEDUCTIBLE:  None
14. YEARLY MAXIMUM LIMIT: None
15. PREEXISTING CONDITIONS: Covered
16. WAITING PERIODS: One (1) plan year on type's IV, V, V, and VI services.

Dental services listed are available at participating provider offices and if within the doctor's expertise to perform said service(s). The "Member Schedule of Services and Co-payments" applies only when treatment is performed by a Dental Care Excellence Plan participating general dentist. Additional dental services not listed may be available at a cost to the member usually and customarily charged by the participating dentist.

   Should the services of a specialist ( periodontist, oral surgeon, pedodontist or orthodontist) be needed, you may refer yourself or you may be referred by your general dentist to any of our participating specialist listed in your plan's participating provider directory. The "Member Schedule of Services and Co-payments" does not apply if treatment is rendered by a specialist or non-participating dentist. The member will be responsible to the specialist for the specialist's usual, customary and reasonable fees less that discount provided by your plan, if any.  Service descriptions are abbreviations of those service descriptions in the most recent editions.
  .
   This web site is intended for marketing purposes and contains plan information similar to or the same as that contained with the Plan's Summary Plan Description and/or policy.
   Any person knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime. This contract is not an insurance policy and is not protected by any Association.