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Detailed and extensive oral evaluation (twice each 12 months).

Evaluación oral detallada y exhaustiva (dos veces cada 12 meses).

Suture of recent small wounds up to 5 cm.

Sutura de heridas pequeñas recientes de hasta 5 cm.

Complicated suture up to 5 cm.

Sutura complicada de hasta 5 cm.

Complicated suture greater than 5 cm.

Sutura complicada mayor de 5 cm.

Surgical revision procedure (once per site every 36 months per tooth).

This health plan includes a voluntary program to reduce member costs for certain specialty drugs. (Refer to policy for more information.)