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TYPE II PROCEDURES (continued) <br />IRERIODONTICS (treatment of disease of the soft tissue or bone surrounding the tooth) <br />- periodontal therapy is not covered unless bone and attachment loss is 4 mm or greater, by quadrant; <br />and confirmed by x -rays and pocket depth charting for each tooth <br />- surgical treatment includes post operative visits <br />- benefits for multiple periodontal surgeries within the same quadrant on the same day will be paid <br />based on the most comprehensive procedure provided that day <br />Gingivectomy or gingivoplasty, by tooth or quadrant <br />Osseous or mucogingival surgery <br />- one per quadrant in each 36 consecutive months <br />Soft tissue graft <br />Bone replacement graft <br />Subepithial connective tissue graft <br />Guided tissue regeneration, per tooth <br />Crown lengthening, per tooth <br />Scaling and root planing, per quadrant, for pathological alveolar bone loss <br />- one treatment per quadrant in each 24 consecutive months <br />Periodontal maintenance cleanings <br />- following active periodontal therapy <br />- four per calendar year; but no more than two in any calendar year if benefits are paid for two routine <br />cleanings in that same calendar year <br />Chemotherapeutics, for areas of refractory disease <br />localized delivery of chemotherapeutic agent by means of a controlled release vehicle <br />- following active periodontal therapy which has failed to resolve the condition <br />- does not include irrigation <br />OEPAIR of PROSTHETICS <br />- no benefits are payable within six months of installation if the repair is provided by the same Dentist <br />who installed the prosthetic <br />Repair of dentures <br />- Repair of complete denture includes repair of broken base and replacement of missing or broken teeth <br />- Repair of partial dentures includes repair of acrylic saddles on base, cast framework, repair or <br />replacement of broken clasp, and replacement of missing or broken teeth <br />Repair or recementation of inlays, crowns and bridges <br />• <br />GL 11 -DP.2 <br />34 09/01/01 <br />