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<br />LIST OF DENTAL PROCEDURES <br /> <br />TYPE I PROCEDURES <br /> <br />DIAGNOSTIC & PREVENTIVE SERVICES <br /> <br />DIAGNOSTIC SERVICES <br />ORAL EXAMINATIONS <br />- up to two per calendar year <br />DENTAL X-RAYS <br />- x-rays taken for orthodontia or for the diagnosis and treatment of craniomandibular or <br />temporomandibular (TMJ) joint disorders are not covered under this provision of this Policy <br />Bitewing films <br />- up to four per calendar year, including any bitewings taken as part of a full mouth or panoramic series <br />Panoramic x-rays, including bitewings; or <br />Full mouth x-rays, with periapical x-rays and bitewings <br />- one complete full mouth or panoramic series in any fIve consecutive years <br />Other dental x-rays, needed to diagnose a specific dental condition <br />- maximum of 6 per calendar year <br /> <br />PREVENTIVE CARE <br />PROPHYLAXIS (Routine Cleanings) <br />- up to two per calendar year <br />- includes scaling, removal of stain and polishing of teeth <br />FLUORIDE TREATMENTS <br />- one treatment per calendar year <br />- for Dependent children through age 15 <br />SPACE MAINT AlNERS (passive Appliance) <br />- for Dependent children through age 15 <br />- for the purpose of maintaining spaces created by the premature loss of primary teeth <br />- includes all adjustments within six months after installation <br />- does not include repairs and replacement costs <br /> <br />GL11-DP.l <br /> <br />31 <br /> <br />09/01/01 <br />