Class I Services
The plan pays 100% of UCR for the following preventive and diagnostic services:
Preventive services, including:
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Cleaning (prophylaxis) two per calendar year, two additional cleanings per year with periodontic issues
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Fluoride application for dependents age 14 and under, two per calendar year
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Sealants for dependents through age 18, once every five years
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Space maintainers.
Diagnostic services, including:
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Routine examination two per calendar year
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Bitewing X-rays two per calendar year
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Full mouth X-rays or panoramic film once every five years.
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