Welborn Health Plans Dental Benefits
Office Visit Co-Pay:$0.00 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; limited to one every 3 years |
| ADA Code | Description | Limitations | |
|---|---|---|---|
| D1110 | Cleaning | One per year |
Choose One per year (A or B):
| 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; limited to one every 3 years |
Choose One per year (A or B):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D7111 | Coronal Remnants – Deciduous Teeth | One per year |
| B | D7140 | Extraction, Erupted Tooth or Exposed Root | One per year |