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 />
7<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 />
D0999 Office visit copayment when FC services are not performed $11 $12<br />
<strong>Preventive</strong> <strong>Services</strong><br />
D11<strong>10</strong> Prophylaxis - adult FC<strong>10</strong> N/B<br />
D1120 Prophylaxis - child FC<strong>10</strong> N/B<br />
D1201 Topical application of fluoride (including prophylaxis) - child FC<strong>10</strong> N/B<br />
D1203 Topical application of fluoride (prophylaxis not included) -<br />
child<br />
FC<strong>10</strong> N/B<br />
D1204 Topical application of fluoride excluding prophylaxis - adult FC<strong>10</strong> N/B<br />
D1205 Topical application of fluoride including prophylaxis - age 14+ FC<strong>10</strong> N/B<br />
D1330 Oral hygiene instructions FC<strong>10</strong> N/B<br />
D1351 Sealant - per tooth (up to 16 years of age) $29 N/B<br />
D15<strong>10</strong> Space maintainer - fixed - unilateral $193 N/B<br />
D1515 Space maintainer - fixed - bilateral $269 N/B<br />
D1520 Space maintainer - removable - unilateral $237 N/B<br />
D1525 Space maintainer - removable - bilateral $269 N/B<br />
D1550 Re-cementation of space maintainer<br />
Restorative <strong>Services</strong><br />
$22 N/B<br />
D2140 Amalgam - one surface, primary or permanent $66 N/B<br />
D2150 Amalgam - two surfaces, primary or permanent $85 N/B<br />
D2160 Amalgam - three surfaces, primary or permanent $<strong>10</strong>2 N/B<br />
D2161 Amalgam - four or more surfaces, primary or permanent $122 N/B<br />
D2330 Resin-based composite - one surface, anterior $80 N/B<br />
D2331 Resin-based composite - two surfaces, anterior $<strong>10</strong>2 N/B<br />
D2332 Resin-based composite - three surfaces, anterior $125 N/B<br />
D2335 Resin-based composite - four or more surfaces or involving<br />
incisal angle (anterior)<br />
$158 N/B<br />
D2391 Resin-based composite - one surface, posterior $<strong>10</strong>4 N/B<br />
D2392 Resin-based composite - two surfaces, posterior $139 N/B<br />
D2393 Resin-based composite - three surfaces, posterior $173 N/B<br />
D2394 Resin-based composite - four or more surfaces, posterior $197 N/B<br />
D25<strong>10</strong> Inlay - metallic - one surface $477 N/B<br />
D2520 Inlay - metallic - two surfaces $538 N/B<br />
D2530 Inlay - metallic - three or more surfaces $584 N/B<br />
D2542 Onlay - metallic - two surfaces $620 N/B<br />
D2543 Onlay - metallic - three surfaces $631 N/B<br />
D2544 <strong>Dental</strong> onlay - metallic - four or more surfaces $635 N/B<br />
D26<strong>10</strong> Inlay - porcelain/ceramic - one surface $523 N/B<br />
D2620 Inlay - porcelain/ceramic - two surfaces $557 N/B<br />
YOU PAY TO<br />
SPECIALIST
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