Class II - Basic Services. A. Direct placement fillings, limited to: 1. Silver amalgam, resin-based composite, compomer, glass-ionomer or equivalent material accepted by the American Dental Association and/or the United States Food and Drug Administration. 2. One filling per twelve (12) months, per tooth, per surface 3. Direct pulp caps and indirect pulp caps B. Non-Surgical periodontal services limited to: 1. Periodontal scaling and root planing one (1) per twenty-four (24) months per quadrant 2. Provision splinting, intracoronal and extracoronal 3. Full mouth debridement to enable comprehensive periodontal procedure once per twenty-four (24) months SAMPLE 4. Periodontal maintenance procedures two (2) per twelve (12) months C. Simple extractions performed without general anesthesia limited to once per tooth per lifetime.
Appears in 4 contracts
Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement
Class II - Basic Services. A. Direct placement fillings, fillings limited to:
1. Silver amalgam, resin-based composite, compomer, glass-ionomer or equivalent material accepted by the American Dental Association and/or the United States Food and Drug Administration.
2. One filling per twelve (12) 12 months, per tooth, per surface.
3. Direct pulp caps and indirect pulp caps.
B. Non-Surgical periodontal surgical periodontic services limited to:
1. Periodontal scaling and root planing one (1) limited to once per twenty-four (24) 24 months per quadrant.
2. Provision splinting, intracoronal and extracoronal.
3. Full mouth debridement to enable comprehensive periodontal procedure once limited to one per twenty-four (24) months 24 months. SAMPLE
4. Periodontal maintenance procedures limited to two (2) per twelve (12) 12 months.
C. Simple extractions performed without general anesthesia limited to once per tooth per lifetime.
Appears in 1 contract
Samples: Student Health Plan Individual Enrollment Agreement
Class II - Basic Services. A. Direct placement fillings, fillings limited to:
1. Silver amalgam, resin-based composite, compomer, glass-ionomer or equivalent material accepted by the American Dental Association and/or the United States Food and Drug Administration.
2. One filling per twelve (12) 12 months, per tooth, per surface.
3. Direct pulp caps and indirect pulp caps.
B. Non-Surgical periodontal surgical periodontic services limited to:
1. Periodontal scaling and root planing one (1) limited to once per twenty-four (24) 24 months per quadrant.
2. Provision splinting, intracoronal and extracoronal.
3. Full mouth debridement to enable comprehensive periodontal procedure once limited to one per twenty-four (24) months SAMPLE24 months.
4. Periodontal maintenance procedures limited to two (2) per twelve (12) 12 months.
C. Simple extractions performed without general anesthesia limited to once per tooth per lifetime.
Appears in 1 contract
Samples: Student Health Plan Individual Enrollment Agreement