Dominion Dental Services FederalDentalPlans com

                                             Endodontic Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D3110 Pulp cap – direct (excluding final restoration) 

$29 

$8 

D3120 Pulp cap – indirect (excluding final restoration) 

$29 

$8 

D3220 Therapeutic pulpotomy (excluding final restoration) 

$72 

$21 

D3221 Pulpal debridement, primary and permanent teeth 

$76 

$22 

D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development 

$96 

$28 

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) 

$96 

$28 

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) 

$96 

$28 

                                              Periodontal Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D4341 Periodontal scaling and root planning – four or more teeth per quadrant 

$105 

$31 

D4342 Periodontal scaling and root planning – one to three teeth, per quadrant 

$71 

$23 

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, 

after oral evaluation 

$48 

$32 

D4910 Periodontal maintenance 

$56 

$16 

                                              Prosthodontic Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D5410 Adjust complete denture – maxillary 

$30 

$9 

D5411 Adjust complete denture – mandibular 

$30 

$9 

D5421 Adjust partial denture – maxillary 

$30 

$9 

D5422 Adjust partial denture – mandibular 

$30 

$9 

D5510 Repair broken denture base – complete 

$56 

$20 

D5520 Replace missing or broken teeth – complete denture (each tooth) 

$56 

$20 

D5610 Repair resin denture base 

$56 

$20 

D5620 Repair cast framework 

$56 

$20 

D5630 Repair or replace broken clasp 

$81 

$24 

D5640 Replace broken teeth – per tooth 

$56 

$20 

D5650 Add tooth to existing partial denture 

$56 

$20 

D5660 Add clasp to existing partial denture 

$56 

$20 

D5670 Replace all teeth and acrylic on cast metal framework, maxillary 

$326 

$109 

D5671 Replace all teeth and acrylic on cast metal framework, mandibular 

$326 

$109 

D5710 Rebase complete maxillary denture 

$184 

$55 

D5711 Rebase complete mandibular denture 

$184 

$55 

D5720 Rebase maxillary partial denture 

$184 

$55 

D5721 Rebase mandibular partial denture 

$184 

$55 

D5730 Reline complete maxillary denture (chairside) 

$111 

$33 

                                              Prosthodontic Services - continued on next page 

16 

2018  

Enroll at www.BENEFEDS.com 

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                                              Prosthodontic Services (cont.) 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D5731 Reline complete mandibular denture (chairside) 

$111 

$33 

D5740 Reline maxillary partial denture (chairside) 

$111 

$33 

D5741 Reline mandibular partial denture (chairside) 

$111 

$33 

D5750 Reline complete maxillary denture (laboratory) 

$165 

$49 

D5751 Reline complete mandibular denture (laboratory) 

$165 

$49 

D5760 Reline maxillary partial denture (laboratory) 

$165 

$49 

D5761 Reline mandibular partial denture (laboratory) 

$165 

$49 

D5850 Tissue conditioning (maxillary) 

$56 

$16 

D5851 Tissue conditioning (mandibular) 

$56 

$16 

D6930 Recement fixed partial denture 

$58 

$17 

D6980 Fixed partial denture repair, by report 

$172 

$124 

                                                      Oral Surgery 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D7111 Extraction, coronal remnants – deciduous tooth 

$45 

$36 

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 

$58 

$47 

D7210 Erupted tooth req. bone cut 

$107 

$86 

D7220 Removal of impacted tooth – soft tissue 

$132 

$106 

D7230 Removal of impacted tooth – partially bony 

$170 

$136 

D7240 Removal of impacted tooth – completely bony 

$200 

$160 

D7241 Removal of impacted tooth – completely bony – with unusual surgical complications 

$220 

$178 

D7250 Removal of residual tooth roots 

$112 

$90 

D7251 Coronectomy – intentional partial tooth removal 

$112 

$90 

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth 

$171 

$137 

D7280 Exposure of an unerupted tooth 

$182 

$63 

D7310 Alveoloplasty in conjunction with extractions – per quadrant 

$96 

$28 

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per 

quadrant 

$82 

$24 

D7320 Alveoloplasty not in conjunction with extractions – per quadrant 

$114 

$34 

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per 

quadrant 

$93 

$28 

D7471 Removal of exostosis 

$206 

$61 

D7510 Incision and drainage of abscess – intraoral soft tissue 

$82 

$24 

D7910 Suture of recent small wounds up to 5 cm 

$34 

$10 

D7921 Collect – apply autologous product 

$40 

$35 

D7971 Excision of pericoronal gingiva 

$77 

$23 

D7999 Unspecified oral surgery procedure, by report 

$0 

$0 

17 

2018  

Enroll at www.BENEFEDS.com 

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