Dominion Dental Services FederalDentalPlans com
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- Bu səhifədəki naviqasiya:
- Periodontal Services Standard Option Copay Amount
- Prosthodontic Services Standard Option Copay Amount
- Prosthodontic Services (cont.) Standard Option Copay Amount
Periodontal Services Standard Option Copay Amount High Option Copay Amount D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces, per quadrant $351
$205 D4211 Gingivectomy or gingivoplasty – one to three teeth, per quadrant $120 $70
D4212 Gingivectomy or gingivoplasty – with restorative procedures, per tooth $40
$30 D4240 Gingival flap procedure, including root planing, four of more contiguous teeth or bounded teeth spaces per quadrant $373
$257 D4241 Gingival flap procedure, including root planing – one to three teeth per quadrant $234 $74
D4249 Clinical crown lengthening-hard tissue $531
$341 D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant $632
$422 D4261 Osseous surgery (including flap entry and closure), one to three contiguous teeth or bounded teeth spaces per quadrant $531
$282 D4268 Surgical revision procedure, per tooth $522 $258
D4270 Pedicle soft tissue graft procedure $592
$381 D4273 Subepithelial connective tissue graft procedures (including donor site surgery) $738 $474
D4275 Soft tissue allograft $613
$394 D4276 Combined connective tissue and double pedicle graft, per tooth $672 $432
D4277 Free soft tissue graft procedure, first tooth or edentulous tooth position in a graft $654
$420 D4278 Free soft tissue graft procedure, each additional contiguous tooth or edentulous tooth position in a graft site $100
$80 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $95 $64
D4381 Localized delivery of antimicrobial agents $25
$7 Prosthodontic Services Standard Option Copay Amount High Option Copay Amount D5110 Complete denture – maxillary $702 $455
D5120 Complete denture – mandibular $702
$455 D5130 Immediate denture – maxillary $758 $511
D5140 Immediate denture – mandibular $758
$511 D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) $477 $306
D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth)
$477 $306
D5213 Maxillary partial denture – cast metal framework with resin denture base (including any conventional clasps, rests and teeth) $802 $549
D5214 Mandibular partial denture – cast metal framework with resin denture base (including any conventional clasps, rests and teeth) $802 $549
D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth) $428
$281 D6010 Endosteal implant – surgical placement $1292 $830
D6011 Second stage implant surgery $200
$200 Prosthodontic Services - continued on next page 20 2018
Enroll at www.BENEFEDS.com Prosthodontic Services (cont.) Standard Option Copay Amount High Option Copay Amount D6013 Surgical placement of mini implant $431 $277
D6055 Connecting bar – implant supported or abutment supported $1213
$780 D6056 Prefabricated abutment – includes modification and placement $343 $220
D6057 Custom fabricated abutment - includes modification and placement $491
$315 D6058 Abutment supported porcelain/ceramic crown $851 $547
D6059 Abutment supported porcelain fused to metal crown – high noble metal $846
$544 D6060 Abutment supported porcelain fused to metal crown – predominantly based metal $754 $485
D6061 Abutment supported porcelain fused to metal crown – noble metal $796
$512 D6062 Abutment supported cast metal crown – high noble metal $834 $536
D6063 Abutment supported cast metal crown – predominantly based metal $742
$477 D6064 Abutment supported cast metal crown – noble metal $776 $499
D6065 Implant supported porcelain/ceramic crown $891
$572 D6066 Implant supported porcelain fused to metal crown – titanium, titanium allow, high noble metal $895
$575 D6067 Implant supported metal crown – titanium, titanium alloy, high noble metal $865 $556
D6068 Abutment supported retainer for porcelain/ceramic FPD $788
$507 D6069 Abutment supported retainer for porcelain fused to metal FPD – high noble metal $843 $542
D6070 Abutment supported retainer for porcelain fused to metal FPD – predominantly base metal $695
$447 D6071 Abutment supported retainer for porcelain fused to metal FPD – noble metal $704 $453
D6072 Abutment supported retainer for cast metal FPD – high noble metal $788
$507 D6073 Abutment supported retainer for cast metal FPD – predominantly base metal $749 $481
D6074 Abutment supported retainer for cast metal FPD – noble metal $758
$487 D6075 Implant supported retainer for ceramic FPD $874 $562
D6076 Implant supported retainer for porcelain fused to metal FPD – titanium, titanium alloy, or high noble metal $823 $529
D6077 Implant supported retainer for cast metal FPD – titanium, titanium alloy, or high noble metal
$872 $560
D6080 Implant maintenance procedures $61
$39 D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant including cleaning of the implant surfaces, without flap entry and closure $71
$23 D6090 Repair implant prosthesis $362 $233
D6091 Replacement of semi-precision or precision attachment $34
$22 D6094 Abutment supported crown – titanium $553 $355
D6095 Repair implant abutment $391
$251 D6100 Implant removal $241 $155
D6194 Abutment supported retainer crown for FPD – titanium $741
$476 D6210 Pontic – cast high noble metal $543 $366
D6211 Pontic – cast predominately base metal $543
$366 Prosthodontic Services - continued on next page 21 2018
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