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