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LIST OF DENTAL PROCEDURES <br />TYPE I PROCEDURES <br />�J <br />DIAGNOSTIC & PREVENTIVE SERVICES <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 />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 MAINTAINERS (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.1 <br />31 09/01/01 <br />