Senior Dental Coverage - Blue Cross Blue Shield of Georgia

Diagnostic and Preventive Care• Coverage begins on your effective date.Care is not subject to a deductible.• The benefit schedule is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.• Two oral examinations and two dentalcleanings per member, per year.• Included single and bitewing X-rays not toexceed $47.PROCEDUREPLAN PAYSInitial or Emergency Oral Exam $14Periodic Oral Exam -limited to 2 exams per member per year $14Bitewing X-rays - single film $8Bitewing X-rays - two films $14Single (periapical) X-rays - first film $8Single X-rays - additional films $8Bitewing X-rays - four films $20Full mouth X-rays -limited to one set every 3 years $40Routine Cleaning -limited to 2 per member per year $315