10 Copayment Preventive Plan - Dominion Dental Services, Inc.

ADA
CODES
DESCRIPTION OF SERVICES
YOU PAY TO
DENTIST
YOU PAY TO
SPECIALIST
D5711 Rebase complete mandibular denture $320 N/B
D5720 Rebase maxillary partial denture $256 N/B
D5721 Rebase mandibular partial denture $256 N/B
D5730 Reline complete maxillary denture (chairside) $207 N/B
D5731 Reline complete mandibular denture (chairside) $208 N/B
D5740 Reline maxillary partial denture (chairside) $205 N/B
D5741 Reline mandibular partial denture (chairside) $205 N/B
D5750 Reline complete maxillary denture (laboratory) $251 N/B
D5751 Reline complete mandibular denture (laboratory) $249 N/B
D5760 Reline maxillary partial denture (laboratory) $242 N/B
D5761 Reline mandibular partial denture (laboratory) $240 N/B
D5820 Interim partial denture (maxillary) $410 N/B
D5821 Interim partial denture (mandibular) $415 N/B
D5850 Tissue conditioning, maxillary $116 N/B
D5851 Tissue conditioning, mandibular
Prosthetics - Fixed
$117 N/B
D6092 Recement supp. crown $67 N/B
D6093 Recement supp. part denture $100 N/B
D6205 Pontic - indirect resin based composite $247 N/B
D6210 Pontic - cast high noble metal $589 N/B
D6211 Pontic - cast predominantly base metal $603 N/B
D6212 Pontic - cast noble metal $566 N/B
D6214 Pontic - titanium $551 N/B
D6240 Pontic - porcelain fused to high noble metal $730 N/B
D6241 Pontic - porcelain fused to predominantly base metal $631 N/B
D6242 Pontic - porcelain fused to noble metal $656 N/B
D6245 Pontic - porcelain/ceramic $716 N/B
D6545 Retainer - cast metal for resin bonded fixed prosthesis $260 N/B
D6602 Inlay - cast high noble metal, two surfaces $407 N/B
D6603 Inlay - cast high noble metal, three or more surfaces $453 N/B
D6604 Inlay - cast predominantly base metal, two surfaces $407 N/B
D6605 Inlay - cast predominantly base metal, three or more surfaces $391 N/B
D6606 Inlay - cast noble metal, two surfaces $371 N/B
D6607 Inlay - cast noble metal, three or more surfaces $412 N/B
D6610 Onlay - cast high noble metal, two surfaces $484 N/B
D6611 Onlay - cast high noble metal >=3 surfaces $529 N/B
D6612 Onlay - cast predominantly base metal, two surfaces $417 N/B
D6613 Onlay - cast predominantly base metal, three or more
surfaces
$462 N/B
D6614 Onlay - cast noble metal, two surfaces $439 N/B
11
Dominion Dental Services USA, Inc., 115 S. Union Street, Suite 300, Alexandria, VA 22314 | Phone: 1-888-518-5338 | Fax: 703-518-8849
KFHP-PREVENTIVE-DEN-FC$10 (1/13)