Plan Information

Fee Schedule

The following fees apply only when services are performed by your selected Dominion general dentist. The below fees do not apply when performed by a Program Specialist (with the exception of Orthodontics). Program Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Program Specialists will provide a reduction from their UCR that will vary between specialists.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient No Charge
D0140 limited oral evaluation - problem focused No Charge
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver No Charge
D0150 comprehensive oral evaluation - new or established patient No Charge
D0160 detailed and extensive oral evaluation - problem focused, by report $67
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) No Charge
D0180 comprehensive periodontal evaluation - new or established patient $36
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $66
D0220 intraoral - periapical first film $14
D0230 intraoral - periapical each additional film $12
D0240 intraoral - occlusal film No Charge
D0250 extraoral - first film No Charge
D0260 extraoral - each additional film No Charge
D0270 bitewing - single film $14
D0272 bitewings - two films $22
D0273 bitewings - three films $27
D0274 bitewings - four films $31
D0277 vertical bitewings - 7 to 8 films $48
D0330 panoramic film $59
D0340 cephalometric film No Charge
D0350 oral/facial photographic images No Charge
D0360 cone beam ct - craniofacial data capture 85%
D0362 cone beam - two-dimensional image reconstruction using existing data, includes multiple images 85%
D0363 cone beam - three-dimensional image reconstruction using existing data, includes multiple images 85%
Tests and Examinations You Pay
D0460 pulp vitality tests $30
D0470 diagnostic casts No Charge
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $15
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult No Charge**
D1120 prophylaxis - child No Charge
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child No Charge
D1204 topical application of fluoride - adult No Charge
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients No Charge
Other Preventive Services You Pay
D1310 nutritional counseling for control of dental disease No Charge
D1320 tobacco counseling for the control and prevention of oral disease No Charge
D1351 sealant - per tooth $28
D1352 preventive resin restoration in a moderate to high caries risk patient - permanent tooth $28
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $176
D1515 space maintainer - fixed - bilateral $250
D1520 space maintainer - removable - unilateral $176
D1525 space maintainer - removable - bilateral $250
D1550 re-cementation of space maintainer $44
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $70
D2150 amalgam - two surfaces, primary or permanent $90
D2160 amalgam - three surfaces, primary or permanent $107
D2161 amalgam - four or more surfaces, primary or permanent $128
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $80
D2331 resin-based composite - two surfaces, anterior $101
D2332 resin-based composite - three surfaces, anterior $124
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $157
D2390 resin-based composite crown, anterior $245
D2391 resin-based composite - one surface, posterior $90
D2392 resin-based composite - two surfaces, posterior $118
D2393 resin-based composite - three surfaces, posterior $149
D2394 resin-based composite - four or more surfaces, posterior $174
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $472
D2520 inlay - metallic - two surfaces $502
D2530 inlay - metallic - three or more surfaces $518
D2542 onlay - metallic-two surfaces $541
D2543 onlay - metallic-three surfaces $575
D2544 onlay - metallic-four or more surfaces $575
D2610 inlay - porcelain/ceramic - one surface $492
D2620 inlay - porcelain/ceramic - two surfaces $522
D2630 inlay - porcelain/ceramic - three or more surfaces $551
D2642 onlay - porcelain/ceramic - two surface $565
D2643 onlay - porcelain/ceramic - three surfaces $593
D2644 onlay - porcelain/ceramic - four or more surfaces $593
D2650 inlay - resin-based composite - one surface $427
D2651 inlay - resin-based composite - two surfaces $479
D2652 inlay - resin-based composite - three or more surfaces $528
D2662 onlay - resin-based composite - two surfaces $555
D2663 onlay - resin-based composite - three surfaces $577
D2664 onlay - resin-based composite - four or more surfaces $577
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $375
D2712 crown - 3/4 resin-based composite (indirect) $589
D2720 crown - resin with high noble metal $619
D2721 crown - resin with predominantly base metal $619
D2722 crown - resin with noble metal $619
D2740 crown - porcelain/ceramic substrate $714
D2750 crown - porcelain fused to high noble metal $677
D2751 crown - porcelain fused to predominantly base metal $677
D2752 crown - porcelain fused to noble metal $677
D2780 crown - 3/4 cast high noble metal $539
D2781 crown - 3/4 cast predominantly base metal $539
D2782 crown - 3/4 cast noble metal $539
D2783 crown - 3/4 porcelain/ceramic $614
D2790 crown - full cast high noble metal $611
D2791 crown - full cast predominantly base metal $611
D2792 crown - full cast noble metal $611
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $61
D2920 re-cement crown $61
D2930 prefabricated stainless steel crown - primary tooth $159
D2931 prefabricated stainless steel crown - permanent tooth $168
D2932 prefabricated resin crown $185
D2940 protective restoration $60
D2950 core buildup, including any pins $167
D2951 pin retention - per tooth, in addition to restoration $36
D2952 post and core in additon to crown, indirectly fabricated $233
D2954 prefabricated post and core in addition to crown $183
D2955 post removal (not in conjunction with endodontic therapy) $149
D2970 temporary crown (fractured tooth) No Charge
D2980 crown repair, by report $127
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $47
D3120 pulp cap - indirect (excluding final restoration) $47
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $112
D3221 pulpal debridement, primary and permanent teeth $112
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $413
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $494
D3330 endodontic therapy, molar (excluding final restoration) $606
D3333 internal root repair of perforation defects $126
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $453
D3347 retreatment of previous root canal therapy - bicuspid $538
D3348 retreatment of previous root canal therapy - molar $653
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $377
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $424
D3425 apicoectomy/periradicular surgery - molar (first root) $498
D3426 apicoectomy/periradicular surgery (each additonal root) $189
D3430 retrograde filling - per root $143
D3450 root amputation - per root $270
Other Endodontic Procedures You Pay
D3920 hemisection (including any root removal), not including root canal therapy $256
D3950 canal preparation and fitting of preformed dowel or post $143
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $369
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $124
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $438
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $131
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $616
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $491
D4268 surgical revision procedure, per tooth $448
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $393
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $138
D4342 periodontal scaling and root planing - one to three teeth per quadrant $78
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $106
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $123
Other Periodontal Services You Pay
D4910 periodontal maintenance $83
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $895
D5120 complete denture - mandibular $895
D5130 immediate denture - maxillary $963
D5140 immediate denture - mandibular $963
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $692
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $692
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $960
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $960
D5225 maxillary partial denture - flexible base (including any clasps, rests and teeth) $960
D5226 mandibular partial denture - flexible base (including any clasps, rests and teeth) $960
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $540
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $51
D5411 adjust complete dentures - mandibular $51
D5421 adjust partial denture - maxillary $51
D5422 adjust partial denture - mandibular $51
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $113
D5520 replace missing or broken teeth - complete denture (each tooth) $99
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $113
D5620 repair cast framework $164
D5630 repair or replace broken clasp $149
D5640 replace broken teeth - per tooth $101
D5650 add tooth to existing partial denture $127
D5660 add clasp to existing partial denture $158
D5670 replace all teeth and acrylic on cast metal framework (maxillary) $358
D5671 replace all teeth and acrylic on cast metal framework (mandibular) $358
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $334
D5711 rebase complete mandibular denture $334
D5720 rebase maxillary partial denture $328
D5721 rebase mandibular partial denture $328
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $212
D5731 reline complete mandibular denture (chairside) $212
D5740 reline maxillary partial denture (chairside) $212
D5741 reline mandibular partial denture (chairside) $212
D5750 reline complete maxillary denture (laboratory) $275
D5751 reline complete mandibular denture (laboratory) $275
D5760 reline maxillary partial denture (laboratory) $271
D5761 reline mandibular partial denture (laboratory) $271
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $449
D5811 interim complete denture (mandibular) $449
D5820 interim partial denture (maxillary) $383
D5821 interim partial denture (mandibular) $383
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $107
D5851 tissue conditioning, mandibular $107
Implant Services
Implant Services You Pay
D6010 surgical placement of implant body: endosteal implant 85%
D6012 surgical placement of interim implant body for transitional prosthesis: endosteal implant 85%
D6040 surgical placement: eposteal implant 85%
D6050 surgical placement: transosteal implant 85%
Implant Supported Prosthetics You Pay
D6053 implant/abutment supported removable denture for completely edentulous arch 85%
D6054 implant/abutment supported removable denture for partially edentulous arch 85%
D6055 dental implant supported connecting bar 85%
D6056 prefabricated abutment - includes placement 85%
D6057 custom abutment - includes placement 85%
D6058 abutment supported porcelain/ceramic crown 85%
D6059 abutment supported porcelain fused to metal crown (high noble metal) 85%
D6060 abutment supported porcelain fused to metal crown (predominantly base metal) 85%
D6061 abutment supported porcelain fused to metal crown (noble metal) 85%
D6062 abutment supported cast metal crown (high noble metal) 85%
D6063 abutment supported cast metal crown (predominantly base metal) 85%
D6064 abutment supported cast metal crown (noble metal) 85%
D6065 implant supported porcelain/ceramic crown 85%
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 85%
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) 85%
D6068 abutment supported retainer for porcelain/ceramic FPD 85%
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) 85%
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 85%
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) 85%
D6072 abutment supported retainer for cast metal FPD (high noble metal) 85%
D6073 abutment supported retainer for cast metal FPD (predominantly base metal) 85%
D6074 abutment supported retainer for cast metal FPD (noble metal) 85%
D6075 implant supported retainer for ceramic FPD 85%
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 85%
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) 85%
D6078 implant/abutment supported fixed denture for completely edentulous arch 85%
D6079 implant/abutment supported fixed denture for partially edentulous arch 85%
Other Implant Services You Pay
D6080 implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis 85%
D6090 repair implant supported prosthesis, by report 85%
D6091 replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment 85%
D6092 recement implant/abutment supported crown 85%
D6093 recement implant/abutment supported fixed partial denture 85%
Implant Supported Prosthetics You Pay
D6094 abutment supported crown - (titanium) 85%
Other Implant Services You Pay
D6095 repair implant abutment, by report 85%
D6100 implant removal, by report 85%
D6190 radiographic/surgical implant index, by report 85%
Implant Supported Prosthetics You Pay
D6194 abutment supported retainer crown for FPD - (titanium) 85%
Other Implant Services You Pay
D6199 unspecified implant procedure, by report 85%
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $611
D6211 pontic - cast predominantly base metal $611
D6240 pontic - porcelain fused to high noble metal $677
D6241 pontic - porcelain fused to predominantly base metal $677
D6242 pontic - porcelain fused to noble metal $677
D6245 pontic - porcelain/ceramic $714
D6250 pontic - resin with high noble metal $619
D6251 pontic - resin with predominantly base metal $619
D6252 pontic - resin with noble metal $619
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $304
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $477
D6600 inlay - procelain/ceramic, two surfaces $522
D6601 inlay - porcelain/ceramic, three or more surfaces $551
D6602 inlay - cast high noble metal, two surfaces $502
D6603 inlay - cast high noble metal, three or more surfaces $518
D6604 inlay - cast predominantly base metal, two surfaces $502
D6605 inlay - cast predominantly base metal, three or more surfaces $518
D6606 inlay - cast noble metal, two surfaces $502
D6607 inlay - cast noble metal, three or more surfaces $518
D6608 onlay - porcelain/ceramic, two surfaces $565
D6609 onlay - porcelain/ceramic, three or more surfaces $593
D6610 onlay - cast high noble metal, two surfaces $541
D6611 onlay - cast high noble metal, three or more surfaces $575
D6612 onlay - cast predominantly base metal, two surfaces $541
D6613 onlay - cast predominantly base metal, three or more surfaces $575
D6614 onlay - cast noble metal, two surfaces $541
D6615 onlay - cast noble metal, three or more surfaces $575
Fixed Partial Denture Retainers-Crowns You Pay
D6720 crown - resin with high noble metal $619
D6721 crown - resin with predominantly base metal $619
D6722 crown - resin with noble metal $619
D6740 crown - porcelain/ceramic $714
D6750 crown - porcelain fused to high noble metal $677
D6751 crown - porcelain fused to predominantly base metal $677
D6752 crown - porcelain fused to noble metal $677
D6780 crown - 3/4 cast high noble metal $539
D6781 crown - 3/4 cast predominantly base metal $539
D6782 crown - 3/4 cast noble metal $539
D6783 crown - 3/4 porcelain/ceramic $614
D6790 crown - full cast high noble metal $611
D6791 crown - full cast predominantly base metal $611
D6792 crown - full cast noble metal $611
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $86
D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated $238
D6972 prefabricated post and core in addition to fixed partial denture retainer $203
D6973 core build up for retainer, including any pins $151
D6975 coping - metal $389
D6976 each additional indirectly fabricated post - same tooth $155
D6977 each additional prefabricated post - same tooth $72
D6980 fixed partial denture repair, by report $206
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $82
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $85
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care You Pay
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $167
D7220 removal of impacted tooth - soft tissue $196
D7230 removal of impacted tooth - partially bony $255
D7240 removal of impacted tooth - completely bony $311
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $364
D7250 surgical removal of residual tooth roots (cutting procedure) $181
Other Surgical Prodecures You Pay
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $315
D7280 surgical access of an unerupted tooth $285
D7291 transseptal fiberotomy/supra crestal fiberotomy, by report $159
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $175
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $258
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $137
Other Repair Procedures You Pay
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $269
Orthodontics
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition $3304
D8080 comprehensive orthodontic treatment of the adolescent dentition $3422
D8090 comprehensive orthodontic treatment of the adult dentition $3658
Other Orthodontic Services You Pay
D8660 pre-orthodontic treatment visit $413
D8670 periodic orthodontic treatment visit (as part of contract) $118
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $64
Anesthesia You Pay
D9210 local anesthesia not in conjunction with operative or surgical procedures No Charge
D9211 regional block anesthesia No Charge
D9212 trigeminal division block anesthesia No Charge
D9220 deep sedation/general anesthesia-first 30 minutes $205
D9221 deep sedation/general anesthesia-each additional 15 minutes $103
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $35
D9241 intravenous conscious sedation/analgesia-first 30 minutes $205
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $103
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $63
Miscellaneous Services You Pay
D9490 Broken Appointment Fee $50
D9910 application of desensitizing medicament $31
D9930 treatment of complications (post-surgical) - unusual circumstances, by report $48
D9940 occlusal guard, by report $328
D9950 occlusion analysis - mounted case $169
D9951 occlusal adjustment - limited $86
D9952 occlusal adjustment - complete $361

Procedures identified with an asterisk (*) exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

** Program covers one additional cleaning per year for diabetics and expecting mothers for a $40 fee.