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 |