Class III - Major Services – Surgical. A. Surgical periodontic services. 1. Gingivectomy or gingivoplasty limited to one (1) treatment per twenty-four (24) months per Member per quadrant or per tooth, and limited to two (2) quadrants per twelve (12) months. 2. Osseous surgery (including flap entry and closure) limited to one (1) treatment per twenty-four (24) months per Member per quadrant. 3. Mucogingival surgery limited to grafts and plastic procedures; one (1) treatment per site. B. Endodontics 1. Apicoectomy, limited to one per Member, per tooth, per lifetime 2. Pulpotomy for deciduous teeth limited to once per tooth per lifetime per Member 3. Root canal for permanent teeth limited to once per tooth per lifetime per Member 4. Root canal retreatment performed on permanent teeth limited to once per tooth per lifetime per Member.
Appears in 4 contracts
Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement
