Class I - Preventive and Diagnostic Services. A. Services limited to twice per Benefit Period. 1. Oral examination including oral health risk assessment. 2. Routine cleaning of teeth (dental prophylaxis). 3. Topical application of fluoride. 4. Bite wing x-ray (not taken on the same date as those in 2.2C below) SAMPLE 5. Intraoral occlusal x-ray. 6. Pulp vitality tests; additional tests may be allowed for accidental injury and trauma, or other emergency. B. Topical fluoride varnish (D1206) limited to eight (8) per twelve (12) months per Member ages zero to two(2) and four (4) per twelve (12) months per Member ages three (3) and above until the end of the Calendar Year in which the Member turns age nineteen (19). C. Services limited to one per thirty-six (36) months: 1. Intraoral complete series x-ray (full mouth x-ray including bitewings) OR one panoramic x-ray and one additional set of bitewing x-rays. 2. One cephalometric x-ray. D. Services limited to once per tooth per sixty (60) months: sealants on permanent molars. E. Services limited to once per quadrant per twenty-four (24) months: space maintainers when Medically Necessary due to the premature loss of a posterior primary tooth. F. Services as required. 1. Palliative treatments once per date of service. 2. Emergency oral exam once per date of service. 3. Periapical and occlusal x-rays limited to the site of injury or infection. 4. Professional consultation rendered by a Dentist, limited to one consultation per condition per Dentist other than the treating Dentist. 5. Temporomandibular joint (TMJ) arthograms, including injection, and other TMJ films, by report.
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Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement
