Common Dental Category In- Out-of- Benefit Limitations and Exclusions Procedures Network Network Filling Basic 10% 20% 1 per tooth per surface per 24 months For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Extraction, Erupted Basic 10% 20% 1 per tooth per lifetime Tooth or Exposed For Limitations and Exclusions, refer Root to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Root Canal Basic 10% 20% 1 per tooth per lifetime For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Scaling and Root Basic 10% 20% 1 per quadrant per 24 months Planing For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Ceramic Crown Major 40% 50% 1 per tooth per 60 months For Limitations and Exclusions, refer to the Covered Services; Major Restorative Services section of your Certificate of Coverage. Removable Partial Major 40% 50% 1 per tooth per 60 months Denture For Limitations and Exclusions, refer to the Covered Services; Prosthodontic Services section of your Certificate of Coverage. 24 month waiting period for replacement of teeth missing prior to member's effective date Extraction, Erupted Basic 10% 20% 1 per tooth per lifetime Tooth with Bone For Limitations and Exclusions, refer Removal to the Covered Services; Basic Restorative Services section of your Certificate of Coverage.