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<br />TYPE II PROCEDURES <br /> <br />BASIC SERVICES <br /> <br />SEALANTS: <br />- for Dependent children through age 15 <br />- for the occlusal surface ofunrestored and non-decayed fIrst and second permanent molars only <br />- one treatment per tooth in any 36 consecutive months <br /> <br />BASIC RESTORATIONS <br />Fillings: amalgam, silicate or composite <br />- benefIts for composite fIllings of posterior teeth will be limited to the amount payable for an <br />equivalent amalgam fIlling <br />- multiple restorations on the same tooth will be treated as one restoration with multiple surfaces; and <br />multiple restorations on one surface or adjacent surfaces will be treated as one restoration <br />Prefabricated stainless steel or resin crowns <br />- for covered Dependent children through age 15 <br />- one per tooth, in any 5 consecutive years <br /> <br />ORAL SURGERY <br />- oral surgery includes local anesthesia and routine post operative visits <br />Simple extraction <br />Surgical removal of erupted tooth <br />Removal of impacted tooth (soft tissue, partially or completely bony) <br />Surgical exposure of impacted or unerupted tooth, to aid eruption <br />- extractions of asymptomatic teeth, except third molars (wisdom teeth), are not covered <br />- where related to orthodontic treatment, extractions and surgical exposure of teeth are not covered <br />under this provision <br />Removal of exposed roots <br />Surgical removal of residual tooth roots <br />Excision of lesions, malignant or benign tumors <br />Radical resection of bone for tumor with bone graft <br />Incision and removal of foreign body from soft tissue <br />Removal of foreign body from bone <br />Maxillary sinusotomy for removal of tooth fragment or foreign body <br />Suture of soft tissue wound <br />- excludes closure of surgical incisions <br />Incision and drainage of abscess, intraoral or extraoral <br />Frenulectomy <br />Sialolithotomy and Sialodochoplasty <br />Dilation of salivary duct <br />Sequestrectomy for osteomyelitis or bone abscess <br />Closure of fistula, salivary or oroantral <br />Reimplantation of tooth or tooth bud <br /> <br />GLII-DP.2h <br />32 <br /> <br />09/01101 <br />