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SUNNYISLES <br />1703779 <br />City of Sunny Isles Beach <br />COVERED DENTAL SERVICES <br />OAfter any applicable deductible is satisfied, Jefferson Pilot Financial Insurance Company covers the following dental <br />services, at the reimbursement rate quoted. <br />Type III and Type IV procedures may be subject to a Benefit Waiting Period.* <br />TYPE I - DIAGNOSTIC & PREVENTIVE SERVICES <br />- ORAL EXAMINATIONS - up to two per calendar year <br />- DENTAL X -RAYS, including: <br />bitewing films - up to four films per calendar year <br />one complete full mouth or panoramic series each five years <br />PROPHYLAXIS (Routine Cleanings) - up to two per calendar year <br />FLUORIDE TREATMENTS - for dependent children through age 15 <br />one treatment per calendar year <br />SPACE MAINTAINERS <br />TYPE II - BASIC SERVICES <br />- FILLINGS <br />- STAINLESS STEEL CROWNS - for dependent children through age 15 <br />- SEALANTS - first and second permanent molars for dependent children through age 15 <br />one application per tooth in three years <br />- ORAL SURGERY - includes extractions and many dental surgeries <br />- PATHOLOGY - biopsy and examination of oral tissue <br />- GENERAL ANESTHESIA and I.V. sedation <br />- EMERGENCY TREATMENT and consultations <br />ENDODONTICS (root canal therapy) <br />PERIODONTAL CLEANINGS - following active periodontal therapy <br />- PERIODONTAL SCALING AND ROOT PLANING - one treatment in 24 months <br />PERIODONTAL SURGERY - including gingivectomy, osseous surgery, and soft tissue graft <br />- REPAIR of DENTURES <br />RECEMENTATION of CROWNS and BRIDGES <br />TYPE III PROCEDURES - MAJOR SERVICES <br />- CROWNS, BRIDGES, and ONLAYS <br />- FULL and PARTIAL DENTURES <br />- ALVEOLAR or GINGIVAL RECONSTRUCTION SURGERY <br />- SURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINT <br />includes synovectomy, myotomy, joint reconstruction, arthrotomy, arthroplasty, arthroscopy and <br />condylectomy <br />TYPE IV PROCEDURES - ORTHODONTICS for dependent children <br />- DIAGNOSTIC SERVICES - examinations, x -rays, and casts or study models <br />- TREATMENT PLAN - including orthodontic extractions <br />- ORTHODONTIC APPLIANCES <br />- TREATMENT OF DISORDERS OF THE TEMPOROMANDIBULAR JOINT <br />includes orthodontic appliances and occlusal orthotic devices <br />*Where Benefit Waiting Periods are included, Prior Carrier Credit may apply. <br />• <br />Jefferson Pilot Financial Insurance Company <br />29 11/2/01 <br />