(206) 282-3600 / 1-800-826-2102 TRUST OFFICE: ZENITH AMERICAN SOLUTIONS DENTAL PLAN B / SCHEDULED BENEFITS / EFFECTIVE APRIL 1, 2011 imum benefit is $2,000 per calendar year per Covered Person. For patients age 0-18, preventive and some minor restorations are not applied to the $2,000 calendar year maximum. For all services, any difference between the dental charge and the Plan s payment schedule will be the patient s responsibility. Exams Two per calendar year Prophylaxis (Cleaning and Scaling) Two per calendar year Periodontal Prophylaxis One every three months One Full Mouth X-ray and One Panoramic X-ray allowed per calendar year; Bitewings are as necessary Fluoride Two per calendar year; Up to age 19 Sealant Allowed for each tooth; Up to age 19 DENTAL PRE-DETERMINATION OF BENEFITS For all dental services in connection with crowns and periodontal treatment, a Dental Treatment Plan must be submitted to the Trust Office for predetermination of benefits. If the Trust determines that alternate procedures, services, or courses of treatment may be performed to correct a dental condition, the maximum amount that Scheduled Plan B will cover is payment for the least expensive procedure which will produce a professionally satisfactory result as determined by the Trust. LIMITATIONS: (1) Oral examinations limited to two per calendar year. (2) Cleaning and Scaling of teeth limited to two per calendar year. (3) Complete mouth x-ray limited to one per calendar year. (4) Fluoride and Sealants limited to age 19. (5) Periodontal prophylaxis limited to one every three months. (6) A prosthetic device will not be provided more than once in every 5-year period. Said 5-year period will be measured from the date on which the existing appliance was last supplied, whether under the current dental agreement or under any prior dental agreement. Services which are necessary to make an appliance satisfactory will be provided in accordance with the agreement. The term existing as used in this paragraph is intended to include an appliance that was placed as the inception of the aforementioned 5-year period, but, for whatever reason, is no longer in the possession of the patient. (7) Services related to the treatment of Temporomandibular Joint Syndrome (TMJ) are limited to a combined medical/dental Plan Lifetime maximum of $1,000.00. (8) Should the patient fail to follow through on a prescribed course of treatment, and subsequently develops a more extensive necessary course of treatment, Plan B shall only be responsible for the initially prescribed course of treatment. EXCLUSIONS: (1) Oral hygiene instruction. (2) Services and supplies furnished solely for cosmetic purposes. (3) Nitrous oxide. (4) Replacement to any existing removable denture or partial denture or fixed bridge unless: a. Additional natural teeth are being replaced. b. The existing denture or bridge either was installed more than 5 years prior to replacement or cannot be made satisfactory. (5) Gold restorations when other materials can be used satisfactorily (i.e. amalgam, composite, resin). (6) Expenses incurred after termination of eligibility from Plan B except for the following: a. Prosthetic devices which are fitted, ordered and pre-certified by the Trust Office prior to termination but were delivered to the Covered Person within 60 days after the date of termination. b. Treatment in process that is completed within 60 days after the date of termination provided that the first visit and plan of treatment were completed prior to date of termination. (7) Charges for treatment when an optional plan of treatment is available at a lesser fee (8) Experimental procedures. (Services and supplies that are, in the Trust s judgment, experimental or investigational. These include any that are not recognized as accepted dental practice in our service area and any for which the required approval of a government agency has not been granted at the time of service.) (9) Services that are not necessary dental care. (10) War related conditions (treatment of any condition caused by, or arising out of, an act of war, armed invasion or aggression). (11) Gnathologic recordings (recording of jaw movement and position). (12) Care, treatment or supplies furnished by a program or agency funded by any government. (13) Charges made for services or supplies furnished while the Covered Person is confined in a Hospital unless such confinement is deemed to be medically necessary and dental treatment in a dental office will cause significant risk to patient s health. (14) DENTAL IMPLANTS AND ALL RELATED SERVICES. (15) EXPENSES FOR ORTHODONTIC TREATMENT OR CORRECTION OF MALOCCLUSION. *** ORTHODONTICS ARE NOT COVERED *** (16) Care and treatment for which there would not have been a charge if no coverage had been in force.
(206) 282-3600 / 1-800-826-2102 DENTAL PLAN B SCHEDULED BENEFITS / PAGE 2 s not listed are not covered by the Dental Plan. 110 64.00 INITIAL ORAL EXAM * 2120 151.00 AMALGAM-2 SURFACES * 120 49.00 PERIODIC ORAL EXAM * 2130 185.00 AMALGAM-3 SURFACES * 130 58.00 EMERGENCY ORAL EXAM 2140 121.00 AMALGAM-1 SURFACE * 140 67.00 LIMITED ORAL EVAL-PROB FOCUSED 2150 151.00 AMALGAM-2 SURFACES * 150 73.00 COMPREHENSIVE ORAL EVALUATION * 2160 185.00 AMALGAM-3 SURFACES * 160 107.00 DETAILED/EXTENSIV EVAL-PROBLEM 2161 140.00 AMALGAM-4+ SURFACES * 170 64.00 RE-EVALUATION-LIMITED FOCUSED 2170 48.00 PIN RETAINED * 180 76.00 COMPREHENSIVE PERIO EVALUATION 2330 149.00 COMPOSIT/RESIN 1 SURF * 210 114.00 FULL MOUTH X-RAYS * 2331 176.00 COMPOSIT/RESIN 2 SURF * 220 23.00 INTRAORAL-SINGLE XRAY * 2332 216.00 COMPOSIT/RESIN 3 SURF * 230 18.00 INTRAORAL-ADDL X-RAY * 2335 255.00 COMPOSITE RESIN * 240 35.00 INTRAORAL-OCCL X-RAY * 2390 250.00 RESIN BASED COMPOSITE CROWN AN 250 45.00 EXTRAORAL-SINGLE XRAY * 2391 162.00 RESIN-BASED COMPOSITE 1 SURF * 260 17.00 EXTRAORAL-ADDL X-RAY * 2392 215.00 2 SURFACE COMPOSITE POSTERIOR * 270 24.00 BITEWING-FIRST X-RAY * 2393 268.00 RESIN-BASED COMPOSITE 3 SURF 272 36.00 BITEWINGS-TWO FILMS * 2394 307.00 4 SURFACE COMPOSITE 274 59.00 BITEWINGS-FOUR FILMS * 2410 518.00 GOLD FOIL-1 SURFACE 277 80.00 VERTICAL BITEWINGS 7-8 FILMS * 2420 615.00 GOLD FOIL-2 SURFACES 290 80.00 FACIAL BONE FILM 2430 764.00 GOLD FOIL-3 SURFACES 310 248.00 SIALOGRAPHY 2510 738.00 GOLD-INLAY 1 SURFACE 330 113.00 PANORAMIC SINGLE XRAY 2520 826.00 GOLD-INLAY 2 SURFACES 415 98.00 BACTERIOLOGIC STUDIES 2530 910.00 GOLD-INLAY 3 SURFACES 460 54.00 PULP VITALITY TESTS 2542 958.00 ONLAY - METALLIC -2 SURFACES 470 92.00 DIAGNOSTIC CASTS 2543 976.00 ONLAY-METALIC 3 SURFACES 472 86.00 ACCESSION OF TISSUE,GROSS EXAM 2544 990.00 ONLAY-METALIC 4 + SURFACES 473 172.00 ACCESSION OF TISSUE,MICRO EXAM 2610 785.00 PORCELAIN INLAY 1-SUR 502 212.00 OTHER ORAL PATHOL PROC, BY RPT 2620 859.00 PORCELAIN INLAY 2-SUR 1110 103.00 PROPHYLAXIS ADULTS * 2630 985.00 PORCELAIN INLAY 3-SUR 1120 67.00 PROPHYLAXIS CHILDREN * 2642 910.00 ONLAY-PORCELAIN/CERAMIC 2 SURF 1201 96.00 PROPHY WITH FLUORIDE - CHILD * 2643 997.00 ONLAY-PORCELAIN/CERAMIC 3 SURF 1203 38.00 TOPICAL APPL FLUORIDE - CHILD * 2644 1,072.00 ONLAY-PORCEL/CERAMIC 4+ SURF 1204 43.00 TOP APP FLOURIDE-ADUL * 2650 745.00 INLAY-COMPOS/RESIN 1 SURFACE 1205 111.00 PROPHY WITH FLUORIDE - ADULT 2651 814.00 INLAY-COMP/RESIN 2 SURFACES 1206 43.00 TOP FLUORIDE VARNISH/MOD-HIRIS 2652 1,101.00 INLAY-COMP/RESIN 3 + SURF 1351 44.00 SEALANT - PER TOOTH * 2662 842.00 ONLAY-COMP/RESIN 2 SURF 1510 224.00 SPACE MAINTAINER * 2663 903.00 ONLAY-COMP/RESIN 3 SURF 1515 401.00 SPACE MAINTAINER * 2664 1,101.00 ONLAY-COMP/RESIN 4 + SURF 1520 373.00 SPACE MAINT-FIXED * 2710 353.00 PLASTIC ACRYLIC CROWN 1525 476.00 SPACE MAINT-REMOVABLE * 2720 896.00 PLASTIC/METAL CROWN 1550 58.00 RECEMENT SPACE MAINT * 2721 381.00 PLASTIC/METAL CROWN 2110 121.00 AMALGAM-1 SURF REST * 2722 762.00 PLASTIC/METAL CROWN
(206) 282-3600 / 1-800-826-2102 DENTAL PLAN B SCHEDULED BENEFITS / PAGE 3 s not listed are not covered by the Dental Plan. 2740 944.00 PORCELAIN CROWN 3346 755.00 RETREATMNT ROOT CANAL-ANTERIOR 2750 516.00 PORCELAIN/METAL CROWN 3347 869.00 RETREATMNT ROOT CANAL-BICUSPID 2751 791.00 PORCELAIN/METAL CROWN 3348 1,097.00 RETREATMNT ROOT CANAL MOLAR 2752 824.00 PORCELAIN/METAL CROWN 3351 555.00 APEXIFICATION 2780 509.00 CROWN 3/4 CAST HIGH NOBLE METL 3352 435.00 APEX/RECALCIFICATION-INTERIM 2781 583.00 CROWN 3/4 CAST PREDOM BASE MTL 3353 451.00 APEX/RECALCIFICATI-FINAL VISIT 2782 672.00 CROWN 3/4 CAST NOBLE METAL 3410 579.00 APICOECTOMY 2783 870.00 CROWN 3/4 PORCELAIN/CERAMIC 3421 647.00 APICOECT/PERIRAD SURG-BICUSP 1 2790 842.00 GOLD FULL CAST CROWN 3425 704.00 APICOECT/PERIRAD SURG-MOLAR 1 2791 746.00 NON-PRECIOUS MET CRN 3426 457.00 APICOECT/PERIRAD SUR EACH ADDL 2792 781.00 SEMI-PRECIOUS MET CRN 3430 192.00 RETROGRADE FILLING 2799 312.00 PROVISIONAL CROWN 3450 282.00 ROOT RESECTION 2910 81.00 RECEMENT INLAYS 3460 874.00 ENDOSSEOUS IMPLANTS 2920 166.00 RECEMENT CROWNS 3470 563.00 INTENTIONAL REIMPLANT W/SPLINT 2930 104.00 PREFAB STAINLESS CROW 3910 146.00 SURG TOOTH ISOLATION 2931 220.00 PREFAB STAINLESS CROW 3920 355.00 HEMISECTION 2932 166.00 PREFAB RESIN CROWN 3950 223.00 CANAL PREP/FITTING 2933 268.00 PREFAB STAINLESS CROWN W/RESIN 4210 567.00 GINGIVECTOMY/OPLASTY (4+TEETH) 2934 294.00 STAINLESS STEEL CROWN PRIMARY 4211 244.00 GINGIVECTOMY/OPLASY (1-3TEETH) 2940 92.00 SEDATIVE FILLINGS 4240 733.00 GINGIVAL FLAP PROC (4+TEETH) 2950 118.00 CROWN BUILDUPS 4241 195.00 GINGIVAL FLAP PROC (1-3 TEETH) 2951 48.00 PIN RETENTION PER TOO 4245 708.00 APICALLY POSITIONED FLAP 2952 304.00 CAST POST AND CORE 4249 771.00 CROWN LENGTHENING HARD TISSUE 2953 343.00 CAST POST W/CROWN 4260 811.00 OSSEOUS SURG (4+ TEETH) QUAD 2954 269.00 PREFAB POST & CORE 4261 685.00 OSSEOUS SURG (1-3 TEETH) QUAD 2957 184.00 ADDL PREFAB POST, SAME TOOTH 4263 350.00 BONE REPLCMNT GRAFT-FIRST SITE 2962 901.00 LABIAL VENEER LAB PRO 4264 276.00 BONE REPLCMNT GRAFT EACH ADDL 2980 166.00 CROWN REPAIR 4265 273.00 BIO MATERIALS AID TISSUE REGEN 3110 42.00 PULP CAP DIRECT 4266 361.00 GUIDED TISS REGENERAT RESORBED 3120 64.00 PULP CAP INDIRECT 4267 878.00 GUIDED TISS REGENERA NONRESORB 3220 94.00 VITAL PULPOTOMY 4268 730.00 SURGICAL REVISION PROCEDURE 3221 158.00 GROSS PULPAL DEBRIDEMENT 4270 817.00 PEDICLE GRAFTS-SOFT 3230 211.00 PULPAL THERAPY ANTERIO/PRIMARY 4271 845.00 FREE SOFT TISS GRAFTS 3240 158.00 PULPAL THERAPY POSTERI/PRIMARY 4273 967.00 SUBEPITHELIAL CONN TISS GRAFT 3310 377.00 ENDODONTIC THERAPY - ANTERIOR 4274 552.00 DISTAL OR PROX WEDGE W/NO SURG 3320 452.00 ENDODONTIC THERAPY-BICUSPID 4275 478.00 SOFT TISSUE ALLOGRAFT 3330 572.00 ENDODONTIC THERAPY-MOLAR 4276 521.00 COMB CONN TISS/DOUBLE PEDICLE 3331 396.00 TRMT OF ROOT CANAL OBSTRUCTION 4320 344.00 SPLINT-INTRACORONAL 3332 342.00 INCOMPLETE ENDODONTIC THERAPY 4321 259.00 SPLINT-EXTRACORONAL 3333 146.00 INTERNAL ROOT REPAIR 4330 121.00 LIMITED OCCL ADJ 3340 572.00 ROOT CANAL-4 CANALS 4341 122.00 PERIODONTAL SCALING-QUAD
(206) 282-3600 / 1-800-826-2102 DENTAL PLAN B SCHEDULED BENEFITS / PAGE 4 s not listed are not covered by the Dental Plan. 4342 130.00 PERIO SCALING & ROOT PLANNING 5811 641.00 DENTURE-TEMPORARY LWR 4355 158.00 FULL MOUTH DEBRIDEMENT 5820 520.00 TEMP PART STAYPLATE U 4910 101.00 PERIODONTAL PROPHY 5821 524.00 TEMP PART STAYPLATE L 5110 609.00 COMPLETE UPR DENTURE 5850 146.00 TISSUE CONDITIONING 5120 604.00 COMPLETE LWR DENTURE 5851 148.00 TISSUE CONDITIONING MANDIBULAR 5130 1,240.00 IMMEDIATE UPR DENTURE 5860 1,617.00 OVERDENTURE COMPLETE 5140 1,233.00 IMMEDIATE LWR DENTURE 5861 1,427.00 OVERDENTURE PARTIAL 5211 701.00 PARTIAL UPR DENTURE 5862 467.00 TOOTH AND CLASP UNIT 5212 701.00 PARTIAL LWR DENTURE 5867 201.00 REPLACE OF PRECISION ATTACHMEN 5213 711.00 PARTIAL UPR DENTURE 6210 449.00 CAST GOLD PONTIC 5214 711.00 PARTIAL LWR DENTURE 6211 849.00 CAST PONTIC 5225 1,468.00 MAXILLARY PARTIAL DENTURE 6212 795.00 CAST PONTIC 5226 1,515.00 MANDIBULAR PARTIAL DENTURE FLX 6240 476.00 PORCELAIN/MET PONTIC 5281 813.00 PARTIAL DENTURE 6241 785.00 PORCELAIN/MET PONTIC 5410 80.00 COMPLETE DENTURE ADJ 6242 817.00 PORCELAIN/MET PONTIC 5411 79.00 ADJU COMP DENTURE LOW 6245 944.00 PONTIC - PORCELAIN/CERAMIC 5421 82.00 PARTIAL DENTURE ADJ 6250 834.00 PLASTIC/METAL PONTIC 5422 80.00 PARTIAL DENTURE ADJ 6251 584.00 PLASTIC/METAL PONTIC 5510 145.00 REPAIR COMPL DEN BASE 6252 751.00 PLASTIC/METAL PONTIC 5520 113.00 REPLACE BROKEN TEETH 6253 104.00 PROVISIONAL PONTIC 5610 69.00 REPAIR DENTURE 6545 367.00 CAST METAL RETAINER 5620 212.00 REPAIR DENTURE 6548 572.00 RETAINER - PORC/CERAM FOR PROS 5630 203.00 REPLACE DENTURE TOOTH 6600 317.00 REPAIR BRIDGE 5640 129.00 REPLACE DENT TOOTH-EA ADDT'L 6601 338.00 INLAY-PORC/CERAMIC, 2 SURF 5650 192.00 ADD TOOTH PART/DENT 6602 350.00 INLAY-CAST HIGH NOBLE METAL,2 5660 232.00 ADD TOOTH/PART DENT 6603 413.00 INLAY-CAST HIGH NOBLE METAL,3+ 5670 818.00 REATTACH DENTURE CLSP 6604 225.00 INLAY-CAST BASE METAL, 2 SURF 5671 818.00 RPLC TEETH/ACRYLIC ON MTL FRAM 6605 288.00 INLAY-CAST BASE METAL, 3+ 5710 506.00 DUPL COMPLETE DENTURE 6606 284.00 INLAY-CAST NOBLE METAL, 2 SURF 5711 487.00 RELEASE COMP LOWER DE 6607 309.00 INLAY-CAST NOBLE METAL, 3+ 5720 390.00 DUPL PARTIAL DENTURE 6608 346.00 ONLAY-PORC/CERAM, 2 SURF 5721 390.00 REL LOWER PARTIAL DEN 6609 363.00 ONLAY-PORC/CERAM, 3+ 5730 316.00 RELINE COMPL DENTURE 6610 413.00 ONLAY-CAST HIGH NOBLE METAL, 2 5731 316.00 RELINE COMPL DENTURE 6611 442.00 ONLAY-CAST HIGH NOBLE METAL,3+ 5740 312.00 RELINE PART DENTURE 6612 288.00 ONLAY-CAST BASE METAL,2 SURF 5741 312.00 RELINE PART DENTURE 6613 317.00 ONLAY-CAST BASE METAL, 3+ 5750 167.00 RELINE COMPL DENTURE 6614 309.00 ONLAY-CAST NOBLE METAL, 2 SURF 5751 378.00 RELINE COMPL DENTURE 6615 330.00 ONLAY-CAST NOBLE METAL, 3+ 5760 371.00 RELINE PART DENTURE 6720 834.00 PLASTIC/METAL CROWN 5761 368.00 RELINE PART DENTURE 6721 626.00 PLASTIC/METAL CROWN 5810 638.00 DENTURE-TEMPORARY UPR 6722 710.00 PLASTIC/METAL CROWN
(206) 282-3600 / 1-800-826-2102 DENTAL PLAN B SCHEDULED BENEFITS / PAGE 5 s not listed are not covered by the Dental Plan. 6740 1,006.00 CROWN PORCELAIN/CERAMIC 7310 228.00 ALVEOLOPLASTY/QUAD 6750 896.00 PORCELAIN/METAL ABUTMENT 7311 178.00 ALVEOPLASTY IN CONJUNCTION WIT 6751 793.00 PORCELAIN/METAL ABUTMENT 7320 270.00 ALVEOLOPLASTY/QUAD 6752 833.00 PORCELAIN/METAL ABUTMENT 7340 686.00 STOMATOPLASTY/ARCH 6780 793.00 GOLD 3/4 CAST ABUTMENT 7350 1,602.00 STOMOPLASTY/ARCH 6781 651.00 BASE METAL 3/4 CROWN 7410 291.00 RADICAL EXCISE-LESION 6782 655.00 NOBLE METAL 3/4 CROWN 7411 280.00 EXCISION OF BENIN LESION >1.25 6783 659.00 PORC/CERAMIC 3/4 CROWN 7412 389.00 EXCISION OF BENIGN LESION,COMP 6790 840.00 GOLD FULL CAST ABUTMENT 7413 572.00 EXCISION OF MALIG LESION <1.25 6791 827.00 NON-PRECIOUS MET ABUTMENT 7414 504.00 EXCISION OF MALIG LESION >1.25 6792 710.00 SEMI-PRECIOUS MET ABUTMENT 7415 812.00 EXCISION OF MALIG LESION,COMP 6793 63.00 PROVISIONAL RETAINER CROWN 7440 452.00 EXCISION TUMOR-LESION 6920 845.00 CONNECTOR BAR 7441 916.00 EXCISION TUMOR-LESION 6930 132.00 RECEMENT BRIDGE 7450 374.00 REMOVE CYST OR TUMOR 6940 315.00 STRESS/BREAKER 7451 504.00 REMOVE CYST OR TUMOR 6950 500.00 PRECISION ATTACHMENT 7460 383.00 REMOVE CYST OR TUMOR 6970 504.00 CAST POST AND CORE 7461 543.00 REMOVE CYST OR TUMOR 6971 353.00 CAST POST/BRIDGE RET. 7470 476.00 REMOVAL OF EXOSTOSIS 6972 297.00 PREFAB POST AND CORE 7471 476.00 REMOVAL OF EXOSTOSIS - P/SITE 6973 209.00 BUILD UP POST & CORE 7472 400.00 REMOVAL OF TORUS PALATINUS 6975 662.00 COPING-METAL 7473 390.00 REMOVAL OF TORUS MANDIBULARIS 6976 271.00 EACH ADDL CAST POST 7485 452.00 SURG REDUCT OSSEOUS TUBEROSITY 6977 145.00 EACH ADDL PREFAB POST 7510 165.00 I & D OF ABSCESS 6980 181.00 BRIDGE REPAIR, BY RPT 7520 343.00 I & D OF ABSCESS 7111 109.00 CORONAL REMNANTS-DECIDUOUS TOO 7530 240.00 REMOVAL FOREIGN BODY 7140 82.00 EXTRACTION, ERUPTED TOOTH 7540 486.00 REMOVE FOREIGN BODIES 7210 226.00 EXTRACT TOOTH ERUPTED 7550 400.00 SEQUESTRECTOMY 7220 277.00 EXTRACT SOFT IMPACT 7560 744.00 MAXILLARY SINUSOTOMY 7230 380.00 EXTRACT PART IMPACT 7910 394.00 SUTURE SIMPLE WOUNDS 7240 296.00 EXTRACT TOTAL IMPACT 7960 401.00 FRENECTOMY 7241 533.00 EXTRACT TOTAL IMPACT 7970 732.00 EXCISION OF TISSUE 7250 256.00 SURG ROOT RECOVERY 7971 361.00 EXC PERICORONAL GINGI 7260 686.00 ORAL FISTULA CLOSURE 9110 97.00 PALLIATIVE TREATMENT 7270 423.00 TOOTH REPLANTATION 9220 338.00 GENERAL ANESTHESIA 7272 572.00 TOOTH TRANSPLANTATION 9221 123.00 GEN ANESTH EACH 15 MI 7280 468.00 SURG EXPOSE OF TOOTH 9241 335.00 INTRAVENOUS SED/ANALG-1ST 30MI 7282 114.00 MOBILIZ ERUPT TOOTH TO AID 9242 106.00 IV SEDATION, EACH ADDL 15 MIN 7285 298.00 BIOPSY OF HARD TISSUE 9310 100.00 PROF CONSULTATION 7286 274.00 BIOPSY OF SOFT TISSUE 9410 181.00 HOUSE CALLS 7290 372.00 SURG REPOSITIONING 9420 352.00 HOSPITAL CALLS 7291 218.00 TRANSSEPTAL FIBEROTOM 9430 62.00 OFFICE VISIT
(206) 282-3600 / 1-800-826-2102 DENTAL PLAN B SCHEDULED BENEFITS / PAGE 6 s not listed are not covered by the Dental Plan. 9440 114.00 OFFICE VISIT 9940 564.00 OCCLUSAL GUARD 9911 32.00 APPLIC OF DESENSITIZING RESIN 9951 121.00 MINOR OCCL ADJUSTMENT 9920 91.00 SPECIAL CONSULTATION 9952 634.00 OCCLUSAL ADJUST COMPL 9930 85.00 POSTSURGICAL TREAT Root Canal Therapy includes treatment plan, clinical procedures and follow-up care; excludes final restoration. Free Soft Tissue Grafts not payable if performed in conjunction with Osseous Surgery or Gingivectomy. Extractions include local anesthesia and routine post-operative care. THERE IS NO MISSING TOOTH CLAUSE. BENEFITS WILL BE CONSIDERED BASED ON THE DATE THE PROSTHETIC IS SEATED.