Preventive/Diagnostic • Three (3) periodic examinations per calendar year, with one (1) comprehensive initial examination per provider per lifetime which is included in the three (3) examinations per calendar year. The examinations include prophylaxes (scaling, cleaning and polishing of teeth). • X-rays include four (4) bitewing x-rays in each calendar year and one (1) full-mouth series or panoramic film every three (3) years. • Two (2) fluoride treatments per calendar year. • Sealants for each covered dependent child from age 6 up to age 14 once per covered tooth (occlusal surface of first and second permanent molars and bicuspids) every three (3) years. • One (1) Space Maintainer per tooth and one (1) mouthguard per dependent child up to age 19 per lifetime. • $1,500 Lifetime Maximum for one (1) nightguard per adult per lifetime. • Two (2) emergency palliative visits for relief of pain per year. Basic Restorative Services: • Extractions (routine removal of tooth/teeth). • Restorations: Inlays, crowns, and Resin based composite fillings. • Pins (once every six months, but not covered if installed in connection with prosthetic service). • Repair of Appliances (repair of dentures including broken or missing teeth or clasps and broken facings; re-cementing of space maintainers, bridges, inlays and crowns.); One (1) per two (2) year period. • Endodontics (root canal therapy) covered one (1) per tooth per lifetime. • Pulpotomy once per tooth per lifetime. • Periodontal coverage for five (5) periodontal treatments per calendar year. One type of periodontal surgery and/or one graft per quadrant.
