BlueMedicare HMO and PPO- Dental Benefits for Covered Services

Office Visit Co-Pay:$0.00 per office visit

CDT ADA Service Description Basic
In-Network
Limitations
D0120 Periodic Oral Evaluation Recall Exam $0 Co-Pay D0120- up to 2 per year OR 1- D0150 and 1- D0120 per year; (D0150 for new patients only; limited to 1 every 3 years)
D0150 Comprehensive Oral Evaluation
D1110 Prophylaxis- ages 14 to Adult 1 per year
D0272 Bitewing, Two Films Either 1 set per year of D0272 or D0274 OR 1 set of Full Mouth X-rays once every 3 years
D0274 Bitewing, Four Films
D7140 Extraction, Erupted Tooth OR Exposed Root Up to 2 Simple Extractions per year
D5410 Adjustment Complete Denture- Maxillary Up to 2 per year of any of the 4 adjustments D5410-D5422
D5411 Adjustment Complete Denture- Mandibular
D5421 Adjustment Part Denture- Maxillary
D5422 Adjustment Part Denture- Mandibular