— A Comprehensive Series or a panoramic X-ray is covered once in a five-year period from the date of service. o Any number or combination of X-rays, with the exception of a Panoramic X-ray, billed for the same date of service, where the combined fees are equal to or exceed the allowed fee for a Comprehensive Series, will be considered a Comprehensive Series for payment and benefit limitation purposes. — A set of Bitewing X-rays (two or more images) are covered once in a benefit period. o A single Bitewing X-ray is covered, there are no Limitations on the number of single Bitewing X-rays a patient can have. Exclusions — Consultations – diagnostic service provided by a dentist other than the requesting dentist — Study models — Diagnostic services and X-rays related to temporomandibular joints (jaw joints) are not a Class I paid covered benefit. Class I Preventive Services Covered Dental Benefits — Prophylaxis (cleaning) — Periodontal maintenance — Sealants — Topical application of fluoride including fluoridated varnishes — Space maintainers — Preventive resin restoration — Application of caries arresting medicament Limitations — Any combination of prophylaxis and periodontal maintenance is covered twice in a calendar year (refer to Class II Periodontics for additional limitation information). o Periodontal maintenance procedures are covered only if a patient has completed active periodontal treatment. — For any combination of adult prophylaxis (cleaning) and periodontal maintenance, third and fourth occurrences may be covered if your gums have Pocket depth readings of 5mm or greater.* *Note: These benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a Confirmation of Treatment and Cost request to determine if the treatment is a covered dental benefit. A Confirmation of Treatment and Cost is not a guarantee of payment. See the “Confirmation of Treatment and Cost” section for additional information. — Topical application of fluoride is limited to two covered procedures in a benefit period. — Sealants: o Benefit coverage for application of sealants is limited to permanent molars that have no restorations (includes preventive resin restorations) on the occlusal (biting) surface. o The application of a sealant is a covered dental benefit once in a three-year period per tooth from the date of service. — Space maintainers are covered once in a patient’s lifetime for the same missing tooth or teeth through age 17. 2024-01-03000-BB 10 LG PPOL 20240101