Common use of COVERED SERVICES INCLUDE Clause in Contracts

COVERED SERVICES INCLUDE. ✓ Oral Examinations ✓ Periapical and bitewing x-rays ✓ Topical fluoride applications for members under age 19 ✓ Prophylaxis, including cleaning, scaling and polishing ✓ Relining of dentures ✓ Repairs of broken removable dentures ✓ Palliative emergency treatment ✓ Routine fillings consisting of silver amalgam and tooth color materials; including stainless steel crowns (primary teeth)* ✓ Simple extractions** ✓ Endodontics-including pulpotomy, direct pulp capping and root canal therapy (excluding restoration) *Payment for an inlay, onlay or crown will equal the amount payable for a three-surface amalgam filling when the member is not covered by Dental Amendatory Rider A. **Payment for a surgical extraction or a hemisection with root removal will equal the amount payable for a simple extraction when the member is not covered by the Dental Amendatory Rider A.

COVERED SERVICES INCLUDE. ✓ Oral Examinations ✓ Periapical and bitewing x-rays ✓ Topical fluoride applications for members under age 19 ✓ Prophylaxis, including cleaning, scaling and polishing ✓ Relining of dentures ✓ Repairs of broken removable dentures ✓ Palliative emergency treatment ✓ Routine fillings consisting of silver amalgam and tooth color materials; including stainless steel crowns (primary teeth)) * ✓ Simple extractions** ✓ Endodontics-including pulpotomy, direct pulp capping and root canal therapy (excluding restoration) *Payment for an inlay, onlay or crown will equal the amount payable for a three-surface amalgam filling when the member is not covered by Dental Amendatory Rider A. **Payment for a surgical extraction or a hemisection with root removal will equal the amount payable for a simple extraction when the member is not covered by the Dental Amendatory Rider A.