ADJUNCTIVE PERIODONTAL SERVICES. A. Provisional splinting - Includes tooth preparation, acid etch, wire, wire placement, acrylic or composite filling, occlusal adjustment, and 3 month follow-up care. Limited to 1 time unit per joint. Replacements must be separated by an interval of at least 24 months.
B. Occlusal adjustment - When performed with periodontal surgery. Limited to 1 time unit per office visit and to 2 times in any 12 month period.
C. Periodontal appliance - Includes impression, insertion and adjustments within 6 months of insertion. Replacements must be separated by an interval of at least 12 months.
