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APPENDIX"C" <br /> <br /> SCHEDULE OF SERVICES <br /> <br />Subject to the exclusions and limitations hereinafter set forth, the following is the Schedule of Services covered by the <br />within Agreement when rendered by a licensed dentist and when necessary and customary, as determined by the <br />standards of generally accepted dental practice. <br /> <br />I. BASIC BENEFITS: <br /> <br /> Diagnostic <br /> Procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment. <br /> <br /> Preventive <br /> Prophylaxis once every six months <br /> Topical application of fluoride solutions <br /> Space maintainers <br /> <br /> Oral Surgery <br /> Procedures for extractions and other oral surgery including pre- and post-operative care. <br /> <br /> General Anesthesia <br /> When administered for a covered oral surgery procedure performed by a dentist. <br /> <br /> Restorative <br /> Provides amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions. Gold <br /> restorations, crowns and jackets will be provided when teeth cannot be restored with the above materials. <br /> <br /> Endodontic <br /> Procedures for pulpal therapy and root canal filling (treatment of non-vital teeth). <br /> <br /> Periodontic <br /> Procedures for treatment of the tissues supporting the teeth. <br /> <br /> II. PROSTHODONTIC BENEFITS: <br /> Procedures for construction of bridges, partial and complete dentures. <br /> <br /> III. EXCLUSIONS <br /> <br /> {a} Services for injuries or conditions which are compensable under Workmen's Compensation or Employer's <br /> Liability Laws; services which are provided the eligible patient by any Federal or State Government Agency or are <br /> provided without cost to the eligibie patient by any municipality, county or other political subdivision, except as <br /> provided in Section 12532.5 of the California Government Code. <br /> <br /> (b) Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry for <br /> purely cosmetic reasons; including but not limited to: cleft palate, maxillary and mandibular malformations, enamel <br /> hypoplasia, fluorosis, and anodontia. <br /> <br /> (c) Prosthodontic Services or Devices (including crowns, and bridges) or anv single procedure started prior to <br /> the date the patient became eligible for such services under this Agreement. <br /> <br /> (d) Prescribed drugs. <br /> <br /> (e) Orthodontic Services. <br /> <br /> <br />