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