Care N' Care Health Plan Dental Benefits
Office Visit Co-Pay:$10.00 per office visit
Choose One per year (A or B):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D0120 | Recall Exam | One per year |
| B | D0150 | Comprehensive Exam | One per year; New Patients only limited to one every 3 years |
Choose One per year (A or B):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D1110 | Cleaning | Ages 14 through adult |
| B | D1120 | Cleaning | Ages 3 through 13 |
Choose One per year (A or B or C):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D0270/D0272/D0273/D0274 | Bitewing X-rays | One set per year |
| B | D0210 | Full Mouth X-rays | One set per year; Allowed once every 3 years |
| C | D0220 | Single X-ray film and up 3 additional D0230 |
Total of 4 films per year |
Choose Two per year:
| ADA Code | Description | Limitations | |
|---|---|---|---|
| D4341 or D4342 | Periodontal Scaling | Total of 2 quadrants per year; requires a pre-estimate |
Choose Two per year:
| ADA Code | Description | Limitations | |
|---|---|---|---|
| DD5410/D5411/D5421/D5422 | Denture Adjustment | Total of 2 quadrants per year; requires a pre-estimate |