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APPENDIX 'C' SCHEDULE OF SERVICES Subject to the exclusions and limitations hereinafter set forth, the following is the Schedule of Services covered by the within Agreement when rendered by a licensed dentist and when necessary and customary, as determined by the standards of generally accepted dental practice. The specific procedure code numbers are listed in Appendix "B". I. BASIC BENEFITS: Diagnostic Procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment. Preventive Prophylaxis as required but not more often than twice in any twelve-month period. Topical application of fluoride solutions. Space maintainers. Oral Surgery Procedures for extractions and other ora~ surgery including pre- and post-operative care. General Anesthesia When administered by a dentist for a covered oral surgery procedure. Restorative Provides amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions. Gold restorations, crowns and jackets will be provided when teeth cannot be restored with the above materials. Endodontic Procedures for pulpal therapy and root canal filling (treatment of non-vital teeth). Periodontic Procedures for treatment of the tissues supporting the teeth. II. PROSTHODONTIC BENEFITS: Procedures for construction of fixed bridges, partial and complete dentures. II1. EXCLUSIONS: (a) Services for injuries or conditions which are compensable under Worker's Compensation or Employer's Liability Laws; services which are provided the eligible petient by any Federa~ or State Government Agency or are provided without cost to ;he eligible patient by any municipality, cour:t¥ or o[he~ pol;t~cal subdivision, except as provided in Section 12532.5 of the Californ;a Government Code. (b) Services with respect to congenital or developmental malformations, other than as provided in the Orthodontic Benefit Rider, or cosmetic surgery or dentistry for purely cosmetic reasons; including but not limited to: cleft palate, maxillary and mandibular malformations, enamel hypoplasia, fluorosis, and anodontia. (c) Prosthodontic Services or Devices (including crowns and bridges) or any single procedure started prior to the date the patient became eligible for such services under this Agreement. (d) Prescribed drugs, premedication or analgesia. (e) Experimental Procedures. (f} Prophylaxis, if the eligible patient has received two prophylaxes covered by the program in the immediately preced- lng eleven months. (g} Procedures, appliances or restorations necessary to increase vertical dimension and/or restore or maintain the oc- clusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, restoration of tooth structure lost from attrition, and restoration for malalignment of the teeth. (h) All hospital costs and any additional fees charged by the dentist for hospital treatment. (i) Charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgery services. (j) Extra oral grafts. 3-76-S-0