Class II - Basic Services Clause Samples

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, as required. SAMPLE B. Non-Surgical periodontal services limited to: 1. Periodontal scaling and root planing, one (1) per twenty-four (24) months per quadrant 2. Splinting, intra-or extra-coronal, natural teeth or prosthetic crowns, as required 3. Full mouth debridement to enable comprehensive periodontal procedure once per twenty-four (24) months 4. Periodontal maintenance procedures two (2) per twelve (12) months C. Simple extractions performed without general anesthesia limited to once per tooth per lifetime. D. Protective (sedative) restoration, as required.

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 12 months, per tooth, per surface, combined In-Network and Out- of-Network. 3. Direct pulp caps and indirect pulp caps. B. Non-Surgical periodontal services limited to: 1. Periodontal scaling and root planing once per 24 months per quadrant, combined In- Network and Out-of-Network. 2. Provision splinting, intracoronal and extracoronal. SAMPLE 3. Full mouth debridement to enable comprehensive periodontal procedure one per 24 months combined In-Network and Out-of-Network. 4. Periodontal maintenance procedures two per 12 months, combined In-Network and Out-of-Network. C. Simple extractions performed without general anesthesia is limited to once per tooth per lifetime.