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 />
13<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 />
D7292 Surgical placement: temp. anchorage device (screw ret.<br />
plate) req. surg. flap<br />
$1,083 N/B<br />
D7293 Surgical placement: temp. anchorage device req. surg. flap $865 N/B<br />
D7294 Surgical placement: temp. anchorage device w/out surg. flap $649 N/B<br />
D73<strong>10</strong> Alveoloplasty in conjunction with extractions - four or more<br />
teeth per quadrant<br />
$145 $171<br />
D7311 Alveoloplasty in conjunction with extractions - one to three<br />
teeth or tooth spaces per quadrant<br />
$126 $149<br />
D7320 Alveoloplasty not in conjunction with extractions - per<br />
quadrant<br />
$187 $220<br />
D7321 Alveoloplasty not in conjunction with extractions $39 $81<br />
D74<strong>10</strong> Excision of benign lesion up to 1.25 cm $182 $215<br />
D7411 Excision of benign lesion > 1.25 cm $179 $2<strong>10</strong><br />
D7412 Excision of benign lesion, complicated $248 $292<br />
D7450 Removal of benign odon cyst/tumor - diam1.25cm $320 $378<br />
D7460 Removal of benign nonodon cyst/tumor - diam1.25cm $345 $408<br />
D7471 Removal of lateral exostosis $303 $357<br />
D7472 Removal of torus palatinus $254 $301<br />
D7473 Removal of torus mandibularis $261 $309<br />
D7485 Surgical reduction of osseous tuberosity $287 $339<br />
D75<strong>10</strong> <strong>Inc</strong>ision and drainage of abscess - intraoral soft tissue $<strong>10</strong>4 $123<br />
D7511 <strong>Inc</strong>ision and drainage of abscess - intraoral $218 $251<br />
D7520 <strong>Inc</strong>ision/drainage of abscess - extra. soft tissue $218 $257<br />
D7521 <strong>Inc</strong>ision and drainage of abscess $152 $175<br />
D7530 Foreign body rem from muc./skin/subcut tissue $152 $180<br />
D7550 Partial ostect/sequestrect non-vital bone rem $254 $301<br />
D79<strong>10</strong> Suture of recent small wounds up to 5 cm $237 $280<br />
D7911 Complicated suture - up to 5 cm $196 $232<br />
D7960 Frenulectomy (frenectomy or frenotomy) - separate<br />
procedure<br />
$257 $303<br />
D7963 Frenuloplasty $96 $237<br />
D7970 Excision of hyperplastic tissue - per arch $441 $520<br />
D7971 Excision of pericoronal gingiva $217 $256<br />
D7972 Surgical reduction of fibrous tuberosity $76 $179<br />
YOU PAY TO<br />
SPECIALIST
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