Dominion Dental Services FederalDentalPlans com

Class C Major 

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 major services.  

•

There is no annual benefit maximum.  

•

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 the 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. 

                                            Major Restorative Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D2510 Inlay – metallic – one surface 

$385 

$247 

D2520 Inlay – metallic – two surfaces 

$444 

$282 

D2530 Inlay – metallic – three or more surfaces 

$487 

$290 

D2542 Onlay – metallic – two surfaces 

$497 

$338 

D2543 Onlay – metallic – three surfaces 

$544 

$363 

D2544 Onlay – metallic – four or more surfaces 

$559 

$380 

D2740 Crown – porcelain/ceramic substrate 

$609 

$417 

D2750 Crown – porcelain fused to high noble metal 

$555 

$380 

D2751 Crown – porcelain fused to predominately base metal 

$555 

$380 

D2752 Crown – porcelain fused to noble metal 

$555 

$380 

D2780 Crown – ¾ cast high noble metal 

$519 

$260 

D2781 Crown – ¾ cast predominately base metal 

$519 

$260 

D2782 Crown – ¾ cast noble metal 

$519 

$260 

D2783 Crown – ¾ porcelain/ceramic 

$549 

$290 

D2790 Crown – full cast high noble metal 

$543 

$366 

D2791 Crown – full cast predominately base metal 

$543 

$366 

D2792 Crown – full cast noble metal 

$543 

$366 

D2794 Crown – titanium 

$543 

$366 

D2950 Core buildup, including any pins 

$133 

$90 

D2954 Prefabricated post and core, in addition to crown 

$164 

$112 

D2980 Crown repair, by report 

$107 

$72 

D2981 Inlay repair 

$107 

$72 

                                            Major Restorative Services - continued on next page 

18 

2018  

Enroll at www.BENEFEDS.com 

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                                            Major Restorative Services (cont.) 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D2982 Onlay repair 

$107 

$72 

D2983 Veneer repair 

$107 

$72 

D2990 Resin infiltration/smooth surface 

$28 

$12 

                                                  Endodontic Services 

Standard 

Option 

Copay 

Amount 

High 

Option 

Copay 

Amount 

D3310 Anterior root canal (excluding final restoration) 

$391 

$260 

D3320 Bicuspid root canal (excluding final restoration) 

$467 

$332 

D3330 Molar root canal (excluding final restoration) 

$587 

$416 

D3346 Retreatment of previous root canal therapy-anterior 

$493 

$290 

D3347 Retreatment of previous root canal therapy-bicuspid 

$569 

$371 

D3348 Retreatment of previous root canal therapy-molar 

$686 

$438 

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, 

root resorption,  etc.) 

$170 

$109 

D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific 

repair of  perforations, root resorption, etc.) 

$496 

$319 

D3353 Apexification/recalcification – final visit (includes completed root canal therapy, apical 

closure/calcific  repair of perforations, root resorption, etc.) 

$378 

$243 

D3355 Pulpal regeneration - initial visit 

$170 

$109 

D3356 Pulpal regeneration - interim medication replacement 

$496 

$319 

D3357 Pulpal regeneration - completion of treatment 

$200 

$150 

D3410 Apicoectomy, anterior 

$416 

$238 

D3421 Apicoectomy, bicuspid (first root) 

$454 

$268 

D3425 Apicoectomy, molar (first root) 

$511 

$283 

D3426 Apicoectomy (each additional root) 

$167 

$112 

D3427 Periradicular surgery w/o apicoectomy 

$344 

$171 

D3428 Bone graft in conj. w/ periradicular surg., per tooth, single site 

$574 

$369 

D3429 Bone graft in conj. w/ periradicular surg., add. contiguous tooth, same site 

$449 

$288 

D3430 Retrograde filling – per root 

$123 

$81 

D3431 Biologic materials to aid soft/osseous tissue regen. in conj. w/ periradicular surg. 

$294 

$189 

D3432 Guided tissue regen., resorbable barrier, per site, in conj. w/ periradicular surg. 

$590 

$379 

D3450 Root amputation – per root 

$264 

$156 

D3920 Hemisection (including any root removal) - not including root canal therapy 

$226 

$145 

19 

2018  

Enroll at www.BENEFEDS.com 

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