10 Copayment Preventive Plan - Dominion Dental Services, Inc.
10 Copayment Preventive Plan - Dominion Dental Services, Inc.
10 Copayment Preventive Plan - Dominion Dental Services, Inc.
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ADA<br />
CODES<br />
DESCRIPTION OF SERVICES<br />
<strong>10</strong><br />
<strong>Dominion</strong> <strong>Dental</strong> <strong>Services</strong> USA, <strong>Inc</strong>., 115 S. Union Street, Suite 300, Alexandria, VA 22314 | Phone: 1-888-518-5338 | Fax: 703-518-8849<br />
KFHP-PREVENTIVE-DEN-FC$<strong>10</strong> (1/13)<br />
YOU PAY TO<br />
DENTIST<br />
D4271 Free soft tissue graft procedure - including donor site $533 $629<br />
D4275 Soft tissue allograft $273 $616<br />
D4276 Combined connective tissue and double pedicle $329 $507<br />
D4320 Provisional splinting - intracoronal $255 $301<br />
D4321 Provisional splinting - extracoronal $193 $227<br />
D4341 Periodontal scaling and root planing - four or more contiguous<br />
teeth or bounded teeth spaces per quadrant<br />
$132 $187<br />
D4342 Periodontal scaling and root planing - one to three teeth per<br />
quadrant<br />
$96 $114<br />
D4355 Full mouth debridement to enable comprehensive<br />
evaluation and diagnosis<br />
$117 $169<br />
D49<strong>10</strong> Periodontal maintenance<br />
Prosthetics - Removable<br />
$80 $<strong>10</strong>6<br />
D51<strong>10</strong> Complete denture - maxillary $817 N/B<br />
D5120 Complete denture - mandibular $817 N/B<br />
D5130 Immediate denture - maxillary $879 N/B<br />
D5140 Immediate denture - mandibular $879 N/B<br />
D5211 Maxillary partial denture - resin base (including any<br />
conventional clasps, rests, and teeth)<br />
$631 N/B<br />
D5212 Mandibular partial denture - resin base (including any<br />
conventional clasps, rests, and teeth)<br />
$631 N/B<br />
D5213 Axillary partial denture - cast metal framework with resin<br />
denture bases (including any conventional clasps, rests, and<br />
teeth)<br />
$876 N/B<br />
D5214 Mandibular partial denture - cast metal framework with resin<br />
denture bases (including any conventional clasps, rests and<br />
teeth)<br />
$876 N/B<br />
D5225 Maxillary partial denture $874 N/B<br />
D5226 Mandibular partial denture $970 N/B<br />
D5281 Removable unilateral partial denture - one piece cast metal<br />
(including clasps and teeth)<br />
$492 N/B<br />
D54<strong>10</strong> Adjust complete denture - maxillary $77 N/B<br />
D5630 Repair or replace broken clasp $134 N/B<br />
D5640 Replace broken teeth - per tooth $85 N/B<br />
D5650 Add tooth to existing partial denture $127 N/B<br />
D5660 Add clasp to existing partial denture $154 N/B<br />
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $540 N/B<br />
D5671 Replace all teeth and acrylic on cast metal framework<br />
(mandibular)<br />
$540 N/B<br />
D57<strong>10</strong> Rebase complete maxillary denture $333 N/B<br />
YOU PAY TO<br />
SPECIALIST
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