Elite Prefered 700 Schedule



SouthEast Personnel Leasing Inc.







DHMO Dental Option (Florida Only)

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DHMO Dental Option (GA Only)

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PPO Dental Option

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Vision Option

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Elite Preferred 700 Schedule of Benefits

Waiting Period for Type I Services:	None
Waiting Period for Type II Services:	None
Waiting Period for Type III Services:	None
Dependent Age:	26
Dependent Maximum Age:	26
Annual Deductible	$50 per person, Max 3 per family, Waived for Type I
Maximum Annual Payment	$1,000

SUMMARY OF BENEFITS

ADA Code	In-Network Reimbursements	Out-of-Network Reimbursements*
	100%	100%

Type I Diagnostic & Preventive

D0120	Periodic Oral Evaluation, Limit 1 per 6 month period
D0140	Limited Oral Evaluation - problem focused
D0150	Comprehensive Oral Evaluation - new or Limit 1 per 2 year period established patient
D0180	Comprehensive periodontal evaluation - new or Limit 1 per 2 year period established patient
D1110, D1120	Prophylaxis Limit 1 per 6 month period
D1201, D1203	Topical Application of Fluoride, per tooth - Limit 1 per 12 month period; limited to children under age 16

ADA Code	In-Network Reimbursements	Out-of-Network Reimbursements*
	80%	80%
Type II Basic Services
D0210	Intraoral - Complete Series, including bitewings - Limit 1 per 3 year period
D0220	Intraoral Periapical x-rays Limit 4 per 12 month period unless in conjunction with operative procedure
D0230	Intraoral Periapical x-rays, each additional film
D0240	Intraoral Occlusal Limit 2 films per 12 month period
D0250, D0260	Extraoral x-rays Limit 2 films per 12 month period
D0270, D0274	Bitewing x-rays Limit 1 set in any 12 month period
D0330	Panoramic film Limit 1 set per 3 year period
D1351	Sealant - per tooth Limit 1 per 3 year period; limited to children under age 16 for non carious molars only
D1510, D1550	Space Maintainers Limited to children under age 16
D2140, D2161	Amalgam Restorations Current amalgam must have been in place for 24 months
D2330, D2335	Composite Resin Restorations-anterior Current composite resin must have been in place for 24 months
D2391, D2394	Composite Resin Restorations-posterior Current composite resin must have been in place for 24 months

ADA Code	In-Network Reimbursements	Out-of-Network Reimbursements*
	50%	50%
Type III Major Services
D2510, D2520 D2530, D2543 D2544, D2610 D2620, D2630 D2642, D2643 D2644, D2650 D2651, D2652 D2662, D2663 D2664	Inlays and Onlays Replacements allowed only if more than 5 years have passed since the last placement of the inlay, onlay and/or crown
D2710, D2721 D2740 D2750-D2752 D2790-D2792	Crowns - Replacements allowed only if more than 5 years have passed since the last placement of the inlay, onlay and/or crown. For patients under 16 years of, age, benefit is limited to plastic and stainless steel crowns
D2910	Re-Cement Inlays
D2920	Re-Cement Crowns
D2930-D2933	Stainless Steel Crowns, Resin Crowns
D2950	Core Build-up including any pins
D2952	Cast Post and Core, in addition to crown
D2954	Prefabricated Post and Core, in addition to crown
D2980	Crown Repair, by report
D3220	Therapeutic Pulpotomy
D3230	Pulpal therapy anterior, primary tooth
D3240	Pulpal therapy posterior, primary tooth
D3310-D3330	Root Canal Therapy
D3346-D3348	Root Canal Therapy - retreatment-by report
D3351-D3353	Apexification
D3410-D3426	Apicoectomy
D3430	Retrograde Filling - per root
D3450	Root Amputation - per root
D3920	Hemisection
D4210, D4211	Gingivectomy or gingivoplasty Per Quadrant - Limit 1 per 36 months
D4240, D4241	Gingival Flap Procedure including root planing Per Quadrant - Limit 1 per 36 months
D4249	Clinical crown lengthening - hard tissue Per Quadrant - Limit 1 per 36 months
D4260, D4261	Osseous Surgery Per Quadrant - Limit 1 per 36 months
D4263	Bone replacement graft - first site in quadrant Per Quadrant - Limit 1 per 36 months
D4264	Bone replacement graft - each additional site in Per Quadrant - Limit 1 per 36 months quadrant
D4266	Guided tissue regeneration - resorbable barrier - Per Quadrant - Limit 1 per 36 months per site - per tooth
D4267	Guided tissue regeneration - nonresorbable Per Quadrant - Limit 1 per 36 months barrier - includes membrane removal, per site - per tooth
D4270	Pedicle Soft Tissue Graft Per Quadrant - Limit 1 per 36 months
D4271	Free soft tissue graft including donor site surgery Per Quadrant - Limit 1 per 36 months
D4273	Subepithelial connective tissue graft procedure Per Quadrant - Limit 1 per 36 months
D4274	Distal or proximal wedge procedure when not Per Quadrant - Limit 1 per 36 months performed in conjunction with surgical procedures in the same anatomical area
D4320, D4321	Provisional Splinting Limit 1 per 12 month period
D4341, D4342	Periodontal Scaling and Root Planing, per quadrant Limit 1 per 24 month period
D4355	Full Mouth Debridement Limit 1 per 24 month period
D4910	Periodontal Maintenance
D5110-D5140	Complete Dentures removable Replacements allowed only if more than 5 years
D5211, D5212 D5213, D5214, D5281	Partial Dentures removable have passed since the last placement of the inlay, onlay and/or crown.
D5410-D5422	Denture Adjustments Limit 3 once denture is 6 months old
D5510, D5520, D5610, D5620, D5630, D5640	Repairs to full and partial dentures Limit 1 per 12 months
D5650	Add tooth to existing partial denture to replace newly extracted functioning natural tooth
D5660	Add clasp to existing partial denture
D5710-D5761	Relining Dentures, Rebasing Dentures
D5850, D5851	Tissue Conditioning - maxillary or mandibular
D6100	Removal of implant, by report
D6211, D6241, D6251 D6602-D6607 D6610-D6615	Fixed Partial Dentures non-precious metal pontics, crown abutments, and metallic retainers; benefits for the replacement of an existing fixed bridge are payable only if the existing bridge is more than 5 years old
D6545 D6721 D6751, D6780, D6791	Cast Metal Retainer for resin bonded fixed partial denture
D6930	Re-Cement fixed partial denture
D6970-D6972	Post and Core in conjunction with a fixed partial denture
D6973	Core Buildup for Retainer including any pins
D6980	Fixed partial denture repair, by report area.
D7111	Coronal remnants, deciduous tooth
D7140	Extraction, erupted tooth or exposed root elevation and/or forceps removal
D7210	Surgical Extractions - except removal of impacted teeth
D7220	Surgical removal of impacted tooth - soft tissue
D7230	Surgical removal of impacted tooth - partially bony
D7240	Surgical removal of impacted tooth - completely bony
D7250	Surgical removal of residual tooth roots cutting procedure
D7260	Oral Antral Fistula Closure
D7261	Primary closure of a sinus perforation
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth.
D7272	Tooth transplantation
D7281	Surgical Exposure of impacted or unerupted tooth to aid eruption.
D7285, D7286	Biopsy of oral tissue
D7310, D7320	Alveoloplasty
D7340, D7350	Vestibuloplasty
D7410, D7411	Excision of benign lesion
D7450, D7451	Removal of benign odontogenic cyst or tumor
D7471	Removal of exostosis maxilla or mandible
D7510, D7520	Incision and Drainage
D7530, D7540	Removal of foreign body
D7960	Frenectomy
D7970	Excision of Hyperplastic tissue - per arch
D7971	Excision of pericoronal gingiva
D7980	Sialolithotomy
D7981	Excision of Salivary Gland, by report
D7982	Sialodochoplasty
D7983	Closure of Salivary Fistula
D9110	Palliative emergency treatment of dental pain
D9220, D9221	Deep sedation/general anesthesia - Covered as a separate procedure only when required for covered complex oral surgical procedures as determined by us

Note: When using an out-of-network provider, benefits are payable based on the Participating Dentist's Fee Schedule.