Coventry Healthcare Dental Benefits
Advantra Elite Benefit
Office Visit Co-Pay:$25.00 per office visit
| CDT | ADA Service Description | Basic In-Network | Limitations |
|---|---|---|---|
| D0120 | Periodic Oral Evaluation | Covered in Full | 1 per year, either D0120 or D0150 (once every 3 years) |
| D0150 | Comprehensive Oral Evaluation | ||
| D0272 | Bitewing, Two Films | 1 per year, either D0272 or D0274 | |
| D0274 | Bitewing, Four Films | ||
| D1110 | Prophylaxis- ages 14 to Adult | 1 per year |
Silver Plus & Silver Advantage Benefit
Office Visit Co-Pay:$25.00 per office visit
| CDT | ADA Service Description | Basic In-Network | Limitations |
|---|---|---|---|
| D0120 | Periodic Oral Evaluation | Covered in Full | 2 per year, either D0120 or D0150 (once every 3 years) |
| D0150 | Comprehensive Oral Evaluation | ||
| D0272 | Bitewing, Two Films | 2 sets per year, either D0272 or D0274 | |
| D0274 | Bitewing, Four Films | ||
| D1110 | Prophylaxis - Adult | 2 per year | |
| D2140 | Amalgam-one surface primary and permanent | Only 1 restoration allowed per year | |
| D2150 | Amalgam-two surface primary and permanent | Only 1 restoration allowed per year | |
| D2160 | Amalgam-three surface primary and permanent | Only 1 restoration allowed per year | |
| D2330 | Composite-One Surface Anterior | Only 1 restoration allowed per year | |
| D2331 | Composite-Two Surface Anterior | Only 1 restoration allowed per year | |
| D2332 | Resin based composite-Three surfaces Anterior | Only 1 restoration allowed per year | |
| D2391 | Resin based composite-One Surface Posterior Permanent | Only 1 restoration allowed per year | |
| D2392 | Resin based composite-Two Surface Posterior Permanent | Only 1 restoration allowed per year | |
| D2393 | Resin based composite-Three Surface Posterior Permanent | Only 1 restoration allowed per year |