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Periodic or routine oral exams once each six months.

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

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

One complete initial oral exam.

Single tooth x-rays as needed.

Bitewing x-rays once each six months.

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

Emergency exams.

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

Silver amalgam fillings (one filling for each tooth surface each 12 months).