Dominion Dental Services FederalDentalPlans com

                                               Prosthodontic Services (cont.) 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D6212 Pontic – cast noble metal 

$543 

$366 

D6214 Pontic – titanium 

$543 

$366 

D6240 Pontic – porcelain fused to high noble metal 

$555 

$380 

D6241 Pontic – porcelain fused to predominately base metal 

$555 

$380 

D6242 Pontic – porcelain fused to noble metal 

$555 

$380 

D6245 Pontic – porcelain/ceramic 

$609 

$417 

D6545 Retainer – cast metal for resin bonded fixed prosthesis 

$260 

$175 

D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis 

$396 

$256 

D6601 Inlay – porcelain/ceramic, three or more surfaces 

$354 

$228 

D6604 Inlay – cast predominantly base metal, two surfaces 

$236 

$152 

D6605 Inlay – cast predominantly base metal, three or more surfaces 

$302 

$194 

D6613 Onlay – cast predominantly base metal, three or more surfaces 

$332 

$213 

D6740 Crown – porcelain/ceramic 

$609 

$417 

D6750 Crown – porcelain fused to high noble metal 

$555 

$380 

D6751 Crown – porcelain fused to predominately base metal 

$555 

$380 

D6752 Crown – porcelain fused to noble metal 

$555 

$380 

D6780 Crown – 3/4 cast high noble metal 

$519 

$260 

D6781 Crown – 3/4 cast predominately base metal 

$519 

$260 

D6782 Crown – 3/4 cast noble metal 

$519 

$260 

D6783 Crown – 3/4 porcelain/ceramic 

$549 

$290 

D6790 Crown – full cast high noble metal 

$543 

$366 

D6791 Crown – full cast predominately base metal 

$543 

$366 

D6792 Crown – full cast noble metal 

$543 

$366 

D6794 Crown – titanium 

$543 

$366 

D9999 Unspecified Adjunctive procedure, by report 

$0 

$0 

Not covered:

• 

Any exclusions or limitations listed under Section 7 of this plan document

22 

2018  

Enroll at www.BENEFEDS.com 

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Class D Orthodontic 

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 orthodontic services.  

•

There is no lifetime maximum for orthodontic services.  

•

See Section 7 of this brochure for plan limitations.

You Pay:

•

In-Network: The co-pay amount shown in the Schedule of Benefits along with a $10 office visit 

copay (please note that the office visit copay is charged per office visit, not per procedure).  

•

Out-of-Network: In full for all charges. There are no out-of-network benefits available except for 

emergency services when the services of an in-network provider are not available. 

                                                  Orthodontic Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D8010 Limited orthodontic treatment of the primary dentition 

$1045 

$1045 

D8020 Limited orthodontic treatment of the transitional dentition 

$1236 

$1236 

D8030 Limited orthodontic treatment of the adolescent dentition 

$1664 

$1664 

D8050 Interceptive orthodontic treatment of the primary dentition 

$1568 

$1568 

D8060 Interceptive orthodontic treatment of the transitional dentition 

$1508 

$1508 

D8070 Comprehensive orthodontic treatment of the transitional dentition (Invisalign - 15% 

discount from participating dentist’s UCR fee) 

$3304 

$3304 

D8080 Comprehensive orthodontic treatment of the adolescent dentition (Invisalign - 15% 

discount from participating dentist’s UCR fee) 

$3422 

$3422 

D8090 Comprehensive orthodontic treatment of the adult dentition (Invisalign - 15% discount 

from participating dentist’s UCR fee) 

$3658 

$3658 

D8210 Removable appliance therapy 

$620 

$620 

D8220 Fixed appliance therapy 

$630 

$630 

D8660 Pre-orthodontic treatment visit 

$78 

$78 

D8670 Periodic orthodontic treatment visit (as part of contract) 

$118 

$118 

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 

$157 

$157 

D8690 Orthodontic retention (alternative billing to a contract fee) 

$504 

$504 

Not covered:

• 

Any exclusions or limitations listed under Section 7 of this plan document

23 

2018  

Enroll at www.BENEFEDS.com 

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