This is a routine cleaning of the teeth for a patient whose gums are in normal condition with no periodontal disease present. A prophylaxis is a preventive treatment. It includes the removal of plaque and calculus ("tartar") from the crown of the tooth, above the gum line. The teeth are also polished. This dental cleaning is covered at no additional cost except for any applicable office visit copayments. Your dentist may determine that you need to have this procedure performed more frequently than every six months. In this case, your plan may have a specific copayment. Please refer to your Schedule of Benefits for plan specifics.