Dominion Dental Services FederalDentalPlans com
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- Bu səhifədəki naviqasiya:
- Preventative Services Standard Option Copay Amount
- Additional Procedures Covered as Basic Services Standard Option Copay Amount
- Prevention Reward Prevention Reward Program
- Class B Intermediate Important things you should keep in mind about these benefits
- See Section 7 of this brochure for plan limitations. You Pay
- Out-of-Network: In full for all charges.
- High Option Copay Amount
Preventative Services Standard Option Copay Amount High Option Copay Amount D1110 Prophylaxis (cleaning) – adult $0 $0
D1110* Additional cleaning (expecting mothers or Diabetics) $40
$40 D1120 Prophylaxis (cleaning) – child $0 $0
D1206 Topical application of fluoride – varnish $0
$0 D1208 Topical application of fluoride $0 $0
D1351 Sealant – per tooth $0
$0 D1352 Preventive resin restoration in a moderate high caries rick patient – permanent tooth $0 $0
D1510 Space maintainer – fixed – unilateral $0
$0 D1515 Space maintainer – fixed – bilateral $0 $0
D1520 Space maintainer – removable – unilateral $0
$0 D1525 Space maintainer – removable – bilateral $0 $0
D1550 Re-cementation of space maintainer $0
$0 D1575 Distal shoe space maintainer – fixed – unilateral $0 $0
Additional Procedures Covered as Basic Services Standard Option Copay Amount High Option Copay Amount D9110 Palliative treatment of dental pain – minor procedure $43 $35
D9995 Teledentistry – synchronous; real-time encounter (when available) $20
$20 D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review (when available) $20
$20 Not covered: • Plaque control programs • Oral hygiene instruction • Dietary instructions • Sealants for teeth other than permanent molars • Over-the-counter dental products, such as teeth whiteners, toothpaste, dental floss· • Any exclusions or limitations listed under Section 7 of this plan document Prevention Reward Prevention Reward Program Each family member enrolled with Dominion who receives two cleanings during the plan year will be reimbursed for their $10 office visit copayments made to the dentist at the time of service (a total reimbursement of $20). Dominion will submit a check for the reimbursement(s) to the primary subscriber at the end of the plan year. If you participate with FSAFEDS, Dominion will coordinate the reimbursement through your FSA. 14
2018 Enroll at www.BENEFEDS.com Class B Intermediate Important things you should keep in mind about these benefits: • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols. • There is no calendar year deductible. • There is no waiting period for intermediate services. • There is no annual benefit maximum. • See Section 7 of this brochure for plan limitations. You Pay: •
copay (please note that the office visit copay is charged per office visit, not per procedure). •
emergency services when the services of an assigned in-network provider are not available.
D2140 Amalgam – one surface, primary or permanent $48 $0
D2150 Amalgam – two surfaces, primary or permanent $62
$0 D2160 Amalgam – three surfaces, primary or permanent $76 $0
D2161 Amalgam – four or more surfaces, primary or permanent $90
$0 D2330 Resin-based composite – one surface, anterior $55 $16
D2331 Resin-based composite – two surfaces, anterior $68
$20 D2332 Resin-based composite – three surfaces, anterior $81 $24
D2335 Resin-based composite – four or more surfaces or involving incisal angle, anterior $83
$24 D2391 Resin-based composite – one surface, posterior $61 $18
D2392 Resin-based composite – two surfaces, posterior $78
$23 D2393 Resin-based composite – three surfaces, posterior $96 $28
D2394 Resin-based composite – four or more surfaces, posterior $110
$33 D2910 Re-cement inlay $38 $12
D2920 Re-cement crown $38
$12 D2930 Prefabricated stainless steel crown – primary tooth $100 $70
D2931 Prefabricated stainless steel crown – permanent tooth $100
$70 D2941 Interim therapeutic restoration – primary dentition $24 $0
D2951 Pin retention – per tooth, in addition to restoration $18
$5 Not Covered: Any exclusions or limitations listed under Section 7 of this plan document 15 2018
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