10 Copayment Preventive Plan - Dominion Dental Services, Inc.

ADA
CODES
DESCRIPTION OF SERVICES
8
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)
YOU PAY TO
DENTIST
D2630 Inlay - porcelain/ceramic - three or more surfaces $643 N/B
D2642 Onlay - porcelain/ceramic - two surfaces $595 N/B
D2643 Onlay - porcelain/ceramic - three surfaces $644 N/B
D2644 Dental onlay - porcelain - four or more surfaces $686 N/B
D2650 Inlay - resin-based composite - one surface $481 N/B
D2651 Inlay - resin-based composite - two surfaces $520 N/B
D2652 Inlay - resin-based composite - three or more surfaces $675 N/B
D2710 Crown - resin (indirect) $268 N/B
D2712 Crown 3/4 resin-based composite (exclusive of veneers) $247 N/B
D2740 Crown - porcelain/ceramic substrate $716 N/B
D2750 Crown - porcelain fused to high noble metal $730 N/B
D2751 Crown - porcelain fused to predominantly base metal $631 N/B
D2752 Crown - porcelain fused to noble metal $656 N/B
D2780 Crown - 3/4 cast high noble metal $699 N/B
D2781 Crown - 3/4 cast predominantly base metal $547 N/B
D2782 Crown - 3/4 cast noble metal $590 N/B
D2790 Crown - full cast high noble metal $652 N/B
D2791 Crown - full cast predominantly base metal $581 N/B
D2792 Crown - full cast noble metal $607 N/B
D2794 Crown - titanium $656 N/B
D2910 Recement inlay $66 N/B
D2915 Recement cast or prefabricated post and core $36 N/B
D2920 Recement crown $66 N/B
D2930 Prefabricated stainless steel crown - primary tooth $137 N/B
D2931 Prefabricated stainless steel crown - permanent tooth $180 N/B
D2932 Prefabricated resin crown $246 N/B
D2934 Prefabricated steel crown primary $106 N/B
D2940 Sedative filling $75 N/B
D2950 Core buildup, including any pins $166 N/B
D2951 Pin retention - per tooth, in addition to restoration $39 N/B
D2952 Cast post and core in addition to crown $244 N/B
D2954 Prefabricated post and core in addition to crown $216 N/B
D2970 Temporary crown (fractured tooth) $182 N/B
D2980 Crown repair, by report $133 N/B
Endodontic Services
D3110 Pulp cap - direct (excluding final restoration) $45 N/B
D3120 Pulp cap - indirect (excluding final restoration) $45 N/B
YOU PAY TO
SPECIALIST