Senior Dental Coverage - Blue Cross Blue Shield of Georgia

Basic Dental Care• Coverage begins after your Plan has beenin effect for six continuous months.• The rate chart is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.PROCEDUREPLAN PAYSFilling - one surface, permanent $36Filling - two surfaces, permanent $44Filling - three surfaces, permanent $55Filling - four or more surfaces, primary $65Extraction - single tooth (simple) $37Extraction - each additional tooth (simple) $37Surgical Extraction $60Removal of Impacted Tooth -soft tissue $85Removal of Impacted Tooth -partial bony $105Removal of Impacted Tooth -complete bony $1306