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Bitewing x-rays of the crowns of the teeth (once each six months).

Full mouth x-rays, seven or more films or panoramic x-ray with bitewing x-rays (once each 60 months).

Study models and casts used in planning treatment (once each 60 months).

Emergency exams.

Preventive Services such as:

Routine cleaning, scaling and polishing of the teeth (once each six months).

Simple tooth extractions.

Fluoride treatment once each six months for members under age 19.

Space maintainers required due to premature loss of teeth for members under age 19.

Sealants applied to permanent premolar and molar surfaces for members under age 14 (one application each 48 months for each premolar or molar surface).