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One complete initial oral exam per provider or location.

Periodic or routine oral exams (twice in 12 months).

Oral exams for a member under age three (twice in 12 months).

Limited oral exams (twice in 12 months).

Single tooth x-rays (no more than one per visit).

Bitewing x-rays (twice in 12 months).

Full mouth x-rays (once in 36 months per provider or location).

Panoramic x-rays (once in 36 months per provider or location).

Routine cleaning, minor scaling and polishing of the teeth (twice in 12 months).

Fluoride treatments (once per calendar quarter).