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 />
9<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 />
YOU PAY TO<br />
SPECIALIST<br />
D3220 Therapeutic pulpotomy (excluding final restoration) -<br />
removal of pulp coronal to the dentinocemental junction<br />
and application of medicament<br />
$<strong>10</strong>0 $118<br />
D33<strong>10</strong> Anterior (excluding final restoration) $425 $488<br />
D3320 Bicuspid (excluding final restoration) $507 $583<br />
D3330 Molar (excluding final restoration) $663 $763<br />
D3346 Retreatment of previous root canal therapy - anterior N/B $588<br />
D3347 Retreatment of previous root canal therapy - bicuspid N/B $784<br />
D3348 Retreatment of previous root canal therapy - molar N/B $1,012<br />
D3351 Apexification/recalcification - initial visit $369 $435<br />
D3352 Apexification/recalcification - interim medication replacement $289 $342<br />
D3353 Apexification/recalcification - final visit $317 $374<br />
D34<strong>10</strong> Apicoectomy/periradicular surgery - anterior $408 $506<br />
D3421 Apicoectomy/periradicular surgery - bicuspid (first root) $455 $633<br />
D3425 Apicoectomy/periradicular surgery - molar (first root) $501 $664<br />
D3426 Apicoectomy/periradicular surgery (each additional root) $304 $358<br />
D3430 Retrograde filling - per root $114 $285<br />
D3450 Root amputation - per root $198 $319<br />
D3920 Hemisection (including any root removal), not including root<br />
canal therapy<br />
Periodontic <strong>Services</strong><br />
$250 $295<br />
D42<strong>10</strong> Gingivectomy or gingivoplasty - four or more contiguous<br />
teeth per quadrant<br />
$359 $424<br />
D4211 Gingivectomy or gingivoplasty - one to three teeth per<br />
quadrant<br />
$155 $184<br />
D4230 Anatomical crown exposure $444 N/B<br />
D4231 Anatomical crown exposure - one to three teeth per quadrant $59 N/B<br />
D4240 Gingival flap procedure, including root planing - four or<br />
more contiguous<br />
$463 $547<br />
D4241 Gingival flap procedure, including root planing - one to<br />
three teeth per quadrant<br />
$117 $231<br />
D4249 Clinical crown lengthening - hard tissue $486 $574<br />
D4260 Osseous surgery (including flap entry and closure) - four or<br />
more per quadrant<br />
$685 $808<br />
D4261 Osseous surgery (including flap entry and closure) - one to<br />
three teeth per quadrant<br />
$437 $516<br />
D4263 Bone replacement graft - first site in quadrant $194 $398<br />
D4265 Biologic material to aid in soft/osseous tissue $163 $199<br />
D4268 Surgical revision procedure, per tooth $376 $543<br />
D4270 Pedicle soft tissue graft procedure $516 $609
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