®
Select Plan1 608x
Great value, fixed fees and special features!
Plan Features
NO Annual Maximums
NO Deductibles
NO Waiting Periods
NO Claim Forms2
NO Pre-authorization Paperwork
NO Pre-existing Condition Exclusions
Select Plan (Same as a DHMO)1
• Choose any in-network dentist from one of the largest DHMO-style networks in the
Mid-Atlantic3
• Family members may select different dentists
• All network dentists are licensed, regulated and must meet Dominion’s Credentialing and Quality Assurance Program standards
• Quality care at predetermined fees
• Extensive coverage for over 250 procedures
• No charge for oral exams, routine semi-annual cleanings, bitewing and complete series X-rays, topical fluoride for children or amalgam fillings (silver)
• Orthodontic benefits provided for adults and children
• Specialty care is also provided by Plan Specialists at rates 25% less than usual and customary charge (Specialty care in Delaware may differ).
• Out-of-Area Emergency Care: You are covered up to $100 for palliative emergency dental treatment arising from accidental injury or illness while temporarily more than 50 miles from home. The $100 limit does not apply in Pennsylvania. 1 Same as a DHMO plan with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no
claim forms (except in the case of out-of-area emergencies).
2 Out-of-area emergency care reimbursement requires a receipt or other proof of loss.
3 Dominion Dental Services, Inc. Competitive Network Survey, 4th
Quarter 2013. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change.
4 Based on the Captiva context fee schedule’s 80th percentile fee information.
5There is a $10 office visit fee.
We Work For Your Benefit.®
For full details of the coverages, limitations and
exclusions, please read the enclosed Description of
Benefits and Member Copayments.
Need to find a participating dentist?
Simply visit DominionDental.com.
Savings Comparison
Procedure
Oral Exam
Bitewing X-rays (2 Films)
Topical Fluoride for Children
Semiannual Cleaning
Complete Series X-rays
Filling (3-Surface/Silver)
Root Canal (Anterior Tooth)
Perio Scaling/Root Planing
Crown (Porcelain/Metal)
Complete Denture
Extraction, Erupted Tooth
Child Orthodontics
Adult Orthodontics
Average
Charge4
Your Fee5
Your
Savings
$79
$41
$36
$87
$133
$186
$736
$258
$1,153
$1,399
$164
$6,570
$6,445
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$225
$76
$361
$502
$45
$3,422
$3,658
100%
100%
100%
100%
100%
100%
69%
71%
69%
64%
73%
48%
43%
How do I enroll?
1. Complete the enclosed enrollment card.
• List all dependents you want covered.
• You must choose a primary care dentist before
or after enrollment. You can find a current list
of dentists online at DominionDental.com/find-
a-dentist. You can also call us at 888-518-5338
to request that one be mailed to you. After your effective date, simply call the dental office you selected and make an appointment. Except for
out-of-area emergency care, you must receive treatment at the dental office you selected.
2. Return the completed enrollment card to your Benefit Administrator or as directed.
3. A Membership Card, Description of Benefits and Member Copayments and Certificate of Coverage will be mailed to you on or before your first day of eligibility.
4. If you have any questions regarding your date of
eligibility, please contact your Benefits Department.
What is my monthly cost?
Subscriber Only$16.24
Subscriber and One Dependent
$26.88
Subscriber and Two or
More Dependents
$36.64
Please note the benefits are licensed dental products,
but they are not pediatric dental essential health
benefits offered by a stand-alone dental plan under the
Affordable Care Act.
Dominion Dental Services, Inc. is licensed as a Dental
Plan Organization in Virginia, Maryland and Delaware,
a Risk Assuming PPO in Pennsylvania and an Accident
and Health Insurer in D.C. Dominion is a Qualified
Health Plan issuer in the DC Health Link, Delaware
Health Insurance Marketplace, Maryland Health
Connection, Pennsylvania Health Insurance Marketplace
and Virginia Health Insurance Marketplace.
Who is eligible?
You and your dependents are eligible. Dependents
include your spouse and unmarried children under
age 26. Refer to your policy documents for further
details regarding your dependent coverage.
What if I change jobs?
If you leave your place of employment, you have the
option of converting your coverage to an alternate
Dominion program using a different method of
payment.
A New Level of Service1
Can I make changes on the Internet?
• Over 98% member retention rate.
Yes. Dominion provides members with secure online
access to:
• ID card requests
• Plan information
• Dentist search
• Dental office transfers
• Contact information
• Member services requests and general correspondence
All changes are confirmed by return email.
For more information, visit DominionDental.
com.
• Less than 0.1% of our members called with a service issue.
•
97% of Dominion members have access to at least two Select Plan dentists within
10 miles.
• 94% first call resolution.
1
Dominion Dental Services, Inc. Internal Performance Report, November 2013.
We Work For Your Benefit.® Dominion Dental Services (Dominion)
115 South Union Street, Suite 300
Alexandria, VA 22314
888-518-5338 (Phone)
855-485-0115 (Fax)
DominionDental.com
is an agile and innovative administrator of dental and vision benefits in the Mid-Atlantic,
offering managed care and indemnity programs, claims adjudication and comprehensive
plan administration. Among our 500,000 customers are leading health plans, employer
groups, municipalities, associations and individuals. The Dominion group of companies
includes Dominion Dental Services, Inc., a licensed issuer of dental plans, and Dominion
Dental Services USA, Inc., a licensed administrator of dental and vision benefits.
0114
Dominion Dental Services, Inc.
Alexandria, VA
DENTAL SELECT PLAN ENROLLMENT CARD
Last Name
First Name
Social Security Number
Sex
M.I.
M
F
Birthdate (MM/DD/YY)
Home Address
Home Phone
City
State
ZIP
Work Phone
Email Address
Hire Date
Dental Office Name & Code # (As indicated on Your Dentist Directory)
List All Your Eligible Dependents Below
Last Name (if different)
First Name
M.I..
Social Security
Number
Sex
(M/F)
Birthdate
(MM/DD/YY)
Spouse
Child
Child
Child
Child
Child
Child
If I am voluntarily paying 100% of the cost of this Plan, without employer contribution, I agree to remain in Plan a minimum
of twelve (12) months. If I cancel before the end of the 12 month period, I may be responsible for the usual, customary and
reasonable charges for services received, reduced by the sum of the subscription dues and copayments paid.
I understand and agree that my signature on this enrollment form serves as my legal commitment to the Plan and its
terms. Further, this signature represents my authorization for the release of information regarding services provided
to me or my covered dependents by dentists and other providers of dental services. Information will be released
to Dominion Dental Services, Inc., for the purpose of investigation or evaluation of care in connection with a claim
or complaint. Authorization will be limited to the term of coverage of this contract. A copy of this form will be made
available to subscriber or their authorized representative upon request.
Signature _____________________________________________________________
PAPERLESS?
Yes
Agent/Broker #
Group #
Date _______________
No
8315
Group Name
Richmond City Public Schools
Coverage Eff. Date
Dominion Dental Services, P.O. Box 75314 Charlotte, NC 28275-5314
Delaware - Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony. District of Columbia - WARNING: It is a
crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially
related to a claim was provided by the applicant. Maryland - Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison. Pennsylvania - Any person who
knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement
of claim containing any materially false information,or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and
civil penalties. Virginia - It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
12DAPP
Richmond Public Schools Employees
Enroll in Dominion’s Select Plan (Dental HMO) and Save!
Great Value, Fixed Fees, Limited Costs and Lower Premiums.
Top 4 Reasons to Choose Dominion’s Select Plan 608x:
1. Lower monthly premiums.
2. One of the largest DHMO-style networks in the Mid-Atlantic.1 Please visit DominionDental.
com to find a participating provider near you.
3. No deductibles, annual maximums, waiting periods or pre-existing condition exclusions.
4. Members receive an average of $1.30 in value for every $1.00 spent on Dominion dental
premium.2
1.
2.
3.
4.
Procedure
Average Cost Without
Dental Coverage3
Dominion Members Pay4
Oral Exam
Full Mouth X-Rays
Semi-Annual Teeth Cleaning
Silver Filling (Three Surfaces)
Root Canal (Anterior)
Periodontal Scaling/Planing
Denture (Complete Upper/Lower)
Crown (Porcelain Fused to Metal)
$79
$133
$87
$186
$736
$258
$1,399
$1,153
$0
$0
$0
$0
$225
$76
$502
$361
Before you enroll, make sure your dentist participates in this plan.
All members must use a participating Select Plan dentist for services.
Dominion Dental Services, Inc. – based on annual review of utilization data.
Based on Context4Healtchcare’s 80th percentile for the Richmond area.
Subject to a $10 office visit copayment.
We Work For Your Benefit.®
Plan 608x
Description of Benefits & Member Copayments
ADA
CODE
BENEFIT
MEMBER
COPAYMENT ($)
DIAGNOSTIC / PREVENTIVE / ADJUNCTIVE
D9439
Office visit..............................................................................$10
D0120
Periodic oral evaluation ..............................................No Charge
D0140
Limited oral evaluation - problem focused .................No Charge
D0150
Comprehensive oral evaluation...................................No Charge
D0160
Detailed and ext. oral eval. - problem focused ............No Charge
D0170
Re-evaluation - limited, problem focused
(established patient; not postoperative visit) ..............No Charge
D0210
Intraoral complete series (including bitewings) ..........No Charge
D0220
Intraoral - periapical first film .....................................No Charge
D0230
Intraoral - periapical each additional film ...................No Charge
D0240
Intraoral - occlusal film ...............................................No Charge
D0250/60
Extraoral - first and each additional film.....................No Charge
D0270/72/74 Bitewing x-ray - one, two or four film(s) ....................No Charge
D0277
Vertical bitewings - seven to eight films .....................No Charge
D0330
Panoramic film .........................................................................25
D0460
Pulp vitality tests .........................................................No Charge
D0470
Diagnostic casts (not in conjunction with Ortho) .......No Charge
D1110
Prophylaxis - teeth cleaning; adult (one per six
months, per member) ..............................................No Charge
D1120
Prophylaxis - teeth cleaning; child (one per six months,
per member. Exclusive of ADA code D1201) ........No Charge
D1201
Topical fluoride with prophylaxis (child)....................No Charge
D1203
Topical fluoride without prophylaxis (child) ..............No Charge
D1310
Nutritional counseling for control and
treatment of dental disease .....................................No Charge
D1320/30
Oral hygiene instructions ............................................No Charge
D1351
Sealant - per tooth (up to 14 years of age) ...............................15
D9110
Palliative (emergency) treatment .............................................33
D9210/15
Local anesthesia ..........................................................No Charge
D9211
Regional block anesthesia ...........................................No Charge
D9212
Trigeminal division block anesthesia ..........................No Charge
D9230
Analgesia, anxiolysis, inhalation of nitrous oxide ...................28
D9310
Consultation (diagnostic service provided by dentist or
specialist other than practitioner providing treatment)........34
D9910
Application of desensitizing medicament ................................17
D9930
Emergency visit during office hours ........................................39
D9990
Broken office appointment - per ½ hour ..................................22
D1510/20
D1515/25
D1550
SPACE MAINTAINERS
Space maintainer fixed/removable - unilateral ....................... 111
Space maintainer fixed/removable - bilateral ........................129
Recementation of space maintainer .........................................28
RESTORATIVE DENTISTRY (FILLINGS)
AMALGAM RESTORATIONS (Silver)
D2140
Amalgam - one surface, primary or permanent..............No Charge
D2150
Amalgam - two surfaces, primary or permanent..............No Charge
D2160
Amalgam - three surfaces, primary or permanent ......No Charge
D2161
Amalgam - four or more surfaces, primary
or permanent ...........................................................No Charge
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2940
D2951
D3110/20
RESIN/COMPOSITE RESTORATIONS (Tooth Colored)
Resin - one surface, anterior ....................................................44
Resin - two surfaces, anterior...................................................51
Resin - three surfaces, anterior.................................................60
Resin - four or more surfaces, anterior ....................................69
Resin - one surface, posterior...................................................47
Resin - two surfaces, posterior .................................................54
Resin - three surfaces, posterior ...............................................63
Resin - four or more surfaces, posterior...................................72
Sedative filling .........................................................................29
Pin retention - per tooth in addition to restoration ...................17
Pulp cap direct/indirect (excl. final rest) ..................................18
ADA
CODE
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720/21/22
D2740
D2750/51/52
D2780/81/82
D2783
D2790/91/92
D2793
D2910/20
D2930
D2931
D2932
D2950
D2952
D2954
D2955
D2970
D2980
BENEFIT
MEMBER
COPAYMENT ($)
Inlay - porcelain/ceramic - one surface ................................$272
Inlay - porcelain/ceramic - two surfaces ................................294
Inlay - porcelain/ceramic - three or more surfaces ................314
Onlay - porcelain/ceramic - two surfaces ..............................327
Onlay - porcelain/ceramic - three surfaces ............................339
Onlay - porcelain/ceramic - four or more surfaces ................339
Inlay - resin-based composite - one surface ...........................258
Inlay - resin-based composite - two surfaces .........................258
Inlay - resin-based composite - three or more surfaces ............258
Onlay - resin-based composite - two surfaces ......................303
Onlay - resin-based composite - three surfaces .....................303
Onlay - resin-based composite - four or more surfaces .........303
Crown - resin-based composite - indirect ..............................196
Crown - 3/4 resin-based composite (excluding veneers) ........381
Crown - resin with metal........................................................309
Crown - porcelain/ceramic substrate ................................399
Crown - porcelain fused to metal ...........................................361
Crown - 3/4 cast with metal ...................................................557
Crown - 3/4 porcelain/ceramic...............................................349
Crown - full cast metal ...........................................................348
Crown - prefabricated stainless steel .....................................103
Recement inlay/crown per unit ................................................31
Crown - prefabricated stainless steel - primary tooth ..............91
Crown - prefabricated stainless steel - permanent tooth ..........99
Crown - prefabricated resin .....................................................99
Core buildup, including any pins .............................................85
Cast post & core in addition to crown ...................................129
Prefabricated post & core in addition to crown .....................106
Post removal (not in conj. w/ endo therapy) ............................76
Temporary crown (w/ perm. crown) ................................No Charge
Crown repair, by report ............................................................72
PROSTHETICS (DENTURES)
D5110/20
Complete upper/lower denture ...............................................502
D5130/40
Immediate upper/lower denture .............................................526
D5211/12
Upper/lower, resin base partial denture (including
any conventional clasps, rests & teeth) .............................489
D5213/14
Upper/lower, cast base partial denture with resin
base (incl. conventional clasps, rests & teeth)...................533
D5281
Removable unilateral partial - one piece cast
cast metal (incl. clasps and teeth) ......................................314
D5410/11
Adjust complete denture, upper/lower .....................................25
D5421/22
Adjust partial denture, upper/lower ........................................25
D5510/5610
Repair denture base (complete or resin) ..................................63
D5520
Replace missing/broken teeth (each tooth) ..............................63
D5620
Repair cast framework .............................................................63
D5630/60
Clasp replaced, repaired or added ............................................82
D5640
Replace broken tooth, per tooth ...............................................63
D5650
Add tooth to existing partial denture .......................................63
D5670/71
Replace all teeth and acrylic on cast metal
framework, upper/lower .........................................................186
D5710/11
Rebase complete denture, upper/lower ..................................201
D5720/21
Rebase partial denture, upper/lower ......................................201
D5730/31
Reline complete denture, upper/lower (chairside) ................ 113
D5740/41
Reline partial denture, upper/lower (chairside)...................... 113
D5750/51
Reline complete upper or lower: lab ......................................176
D5760/61
Reline upper/lower partial: lab...............................................176
D5810/11
Interim complete denture, upper/lower ..................................276
D5820/21
Interim partial denture, upper/lower ......................................276
D5850/51
Tissue conditioning, upper/lower .............................................53
BRIDGE & PONTICS
D6210/11/12
Pontic - metal .........................................................................348
D6240/41/42 Pontic - porcelain fused to metal ...........................................361
D6245
Pontic - porcelain/ceramic........................................................396
D6250/51/52 Pontic - resin with metal ........................................................309
CROWN & BRIDGE
D6545
Retainer - cast metal for a resin bonded fixed prothesis.............187
D2390
Resin based composite crown, anterior .................................134
D6548
Retainer - porcelain/ceramic for resin
D2510
Inlay - metallic - one surface .................................................282
bonded fixed prosthesis .....................................................293
D2520
Inlay - metallic - two surfaces ................................................282
D6600
Inlay - porcelain/ceramic, two surfaces .................................162
D2530
Inlay - metallic - three or more surfaces ................................290
D6601
Inlay - porcelain/ceramic, three or more surfaces ..................173
D2542
Onlay - metallic - two surfaces ..............................................338
D6602
Inlay - cast high noble metal, two surfaces ............................180
D2543
Onlay - metallic - three surfaces ............................................380
D6603
Inlay - cast high noble metal, three or more surfaces ..............212
D2544
Onlay - metallic - four or more surfaces ................................380
D6604
Inlay - cast predom. base metal, two surfaces ..................... $116
Form608x-VA
All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.
Plan 608x
ADA
CODE
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6720/21/22
D6740
D6750/51/52
D6780
D6781
D6782
D6783
D6790/91/92
D6930
D6970/71
D6972
D6973
D6975
D6976
D6977
D6980
BENEFIT
MEMBER
COPAYMENT ($)
Inlay - cast predom. base metal, three or more surfaces ............148
Inlay - cast noble metal, two surfaces ....................................146
Inlay - cast noble metal, three or more surfaces ....................158
Onlay - porcelain/ceramic, two surfaces ................................178
Onlay - porcelain/ceramic, three or more surfaces ................186
Onlay - cast high noble metal, two surfaces............................212
Onlay - cast high noble metal, three or more surfaces ............227
Onlay - cast predom. base metal, two surfaces ......................148
Onlay - cast predom. base metal, three or more surfaces .............162
Onlay - cast noble metal, two surfaces ..................................158
Onlay - cast noble metal, three or more surfaces ...................169
Crown - resin w/ metal...........................................................309
Crown - porcelain/ceramic.......................................................396
Crown - porcelain to metal ....................................................361
Crown - 3/4 cast high noble metal .........................................348
Crown - 3/4 cast predominantly base metal ...........................336
Crown - 3/4 cast noble metal .................................................344
Crown - 3/4 porcelain/ceramic...............................................350
Crown - full cast metal ...........................................................348
Recement fixed partial bridge ..................................................46
Cast post & core ....................................................................129
Prefabricated post & core - in addition to bridge retainer .....106
Core buildup for retainer, including any pins ..........................85
Coping - metal........................................................................222
Each additional cast post - same tooth .....................................88
Each additional prefabricated post - same tooth ..........................41
Fixed partial denture repair, by report.................................... 117
ENDODONTICS1
D3220
Therapeutic pulpotomy (excl. final rest) ..................................54
D3221
Pulpal debridement, primary and perm. teeth ..............................58
D3310
Anterior (excl. final rest) ........................................................225
D3320
Bicuspid (excl. final rest) .......................................................290
D3330
Molar (excl. final rest)...........................................................361
D3333
Internal root repair of perforation defects ................................65
D3346
Re-treatment - anterior ...........................................................251
D3347
Re-treatment - bicuspid ..........................................................322
D3348
Re-treatment - molar ..............................................................380
D3410
Apicoectomy/periradicular surgery, anterior .........................206
D3421
Apicoectomy - bicuspid (first root) ........................................232
D3425
Apicoectomy - molar (first root) ............................................245
D3426
Apicoectomy - (each additional root) ......................................97
D3430
Retrograde filling - per root .....................................................77
D3450
Root amputation - per root .....................................................135
D3920
Hemisection (including any root removal) ............................135
D3950
Canal prep/fit of preformed dowel or post ...............................97
PERIODONTICS1
D0180
Comprehensive periodontal evaluation - new or
established patient - not in conjunction with D0150,
limited to once per 18 months .............................................35
D4210
Gingivectomy/gingivoplasty - four or more teeth
per quad. ............................................................................187
D4211
Gingivectomy/gingivoplasty one-to-three teeth
per quad. ..............................................................................64
D4240
Gingival flap procedure, including root planing, per quad. ............277
D4241
Gingival flap procedure, including root planingone-to-three teeth, per quadrant...........................................67
D4260
Osseous (bone) surgery - four or more per quad. ..................386
D4261
Osseous (bone) surgery - one - three teeth per quad. .............258
D4268
Surgical revision procedure, per tooth ...................................236
D4274
Distal or proximal wedge procedure .....................................206
D4341
Perio scaling & root planing four or more per quad. ..................76
D4342
Perio scaling & root planing one-to-three teeth per quad. ...............41
D4355
Full mouth debridement ...........................................................58
D4381
Localized delivery of chemotherapeutic agents via a
controlled release vehicle into diseased crevicular
tissue, per tooth, by report ...................................................64
D4910
Periodontal maintenance ..........................................................59
D9940
Occlusal guard by report ........................................................197
D9950
Occlusion analysis - mounted case ..........................................70
D9951
Occlusal adjustment, limited ....................................................44
D9952
Occlusal adjustment, complete ..............................................182
ORAL SURGERY1
D7111
Extraction, coronal remnants - deciduous tooth ......................24
D7140
Extraction - erupted tooth or exposed root ..............................45
D7210
Surgical extraction - erupted tooth ...........................................92
D7220
Removal of impacted tooth - soft tissue ................................ 111
D7230
Removal of impacted tooth - partially bony ..........................131
ADA
CODE
D7240
D7241
D7250
D7270
D7280
D7291
D7310/20
D7510
D7960
1
BENEFIT
MEMBER
COPAYMENT ($)
Removal of impacted tooth - completely bony ....................$164
Removal of impacted tooth - completely bony,
with unusual surgical complications .................................144
Removal of residual tooth roots ...............................................98
Tooth reimplantation and/or stabilization of accidentally
evulsed or displaced tooth and/or alveolus........................148
Surgical access of an unerupted tooth ......................................93
Trasseptal fiberotomy/supra crestal fiberotomy,
by report ..............................................................................37
Alveoloplasty per quadrant .....................................................92
Incision/draining of abscess, soft tissue ...................................63
Frenulectomy (frenectomy or frenotomy) .............................162
As performed by a Particpating General Dentist. See Plan Exclusion #15.
ORTHODONTICS2
D8660
Pre-orthodontic treatment visit, records and models ...............413
D8070
Comprehensive orthodontic treatment of the
transitional dentition .......................................................3,304
D8080
Comprehensive orthodontic treatment of
adolescent dentition ........................................................3,422
D8090
Comprehensive orthodontic treatment of adult
dentition ..........................................................................3,658
D8670
Periodic orthodontic visit (beyond 24 months of
treatment) per month charge .............................................. 118
D8680
Orthodontic retention (removal of appliances,
construction and placement of retainer(s)) ........................413
2
Phase I Treatment (D8010 - D8050) is provided at a 15% reduction from the
orthodontist’s UCR fees. See limitation #17 for additional coverage exclusions.
Plan Exclusions
1. Services for injuries or conditions which are covered under worker’s compensation and
employer’s liability laws. Services which are provided without cost to Subscribers by any
federal, state, municipal, county or other subdivision’s program (with the exception of
Medicaid).
2. Services which, in the opinion of the attending dentist, are not necessary for the patient’s
dental health.
3. Cosmetic, elective or aesthetic dentistry.
4. Oral surgery requiring the setting of fractures or dislocations.
5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital,
anodontic, mandibular prognathism or development malformations where, in the sole
discretion of the Participating Dentist, such services should not be performed in a dental
office.
6. Dispensing of drugs.
7. Hospitalization for any dental procedure.
8. Treatment required for conditions resulting from major disaster, epidemic or war, including
declared or undeclared war or acts of war.
9. Replacement due to loss or theft of prosthetic appliance.
10. General anesthesia and sedation.
11. Implantation and related restorative procedures.
12. Unlisted procedures.
13. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or Dominion Dental Services, Inc. (with the exception of outof-area emergency dental services).
14. Services related to the treatment of TMD (Temporal Mandibular Disorder).
15. Services related to procedures that are of such a degree of complexity as to not be
normally performed by a Participating General Dentist. Above copayments do not apply
when performed by a Plan Specialist (with the exception of orthodontics). Plan Specialist,
if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees,
except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction
from their UCR that will vary between specialists.
16. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic
impacted teeth.
17. The Invisalign system and similar specialized braces are not a covered benefit. Patient
copayments will apply to the routine orthodontic appliance portion of services only.
Additional costs incurred will become the patient’s responsibility.
Plan Limitations
1. Replacement of a bridge, crown or denture within five (5) years after the date it was
originally installed.
2. Replacement of filling within two (2) years after original date of placement.
3. Teeth cleaning (prophylaxis) at intervals of less than six (6) months.
4. Crown and bridge fees apply to treatment involving five or fewer units when presented in
a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are
available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.
5. Full mouth x-rays or panoramic film – one set every three years.
6. Retreatment of root canal within two (2) years of the original treatment.
7. Limit 4381 to one benefit per tooth for three teeth per quadrant or a total of 12 teeth for
all four quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or
greater.
Only current ADA CDT codes are considered valid by Dominion Dental Services, Inc.
Current Dental Terminology © American Dental Association.
Select Plan** Dentist Directory
Central Virginia - General Dentists
* Not accepting new members.
+ Discount Program not accepted.
HA Handicap Accessible
We are continually expanding our network of dentists. For the most up-to-date listing of all participating general dentists and specialists visit us online
at DominionDental.com/find-a-dentist. A printed list can also be requested by calling our Member Service Department toll-free at 888-518-5338.
CHESTERFIELD
Chester
#2817
Shwetha Rodrigues DDS PC
12619 Jefferson Davis Hwy
Chester, VA 23831
(804) 748-2555
Language(s): Sign Language
Chesterfield
#100
HA
William H. Rhea, D.D.S.
10108 Krause Rd #102
Chesterfield, VA 23832
(804) 751-0609
Extended Office Hours
Midlothian
#5
John J Kim DDS
2927 Polo Pkwy
Midlothian, VA 23113
(804) 378-9100
Language(s): Korean
HA
#33886
Railey Hill Dental
125 Browns Way Rd
Midlothian, VA 23114
(804) 378-0082
Richmond
#99
HA
Dr. Oley and Quilez, D.D.S., PLC
1907 W Huguenot Rd
Richmond, VA 23235
(804) 379-6806
Language(s): French, Korean, Spanish
HA
#55
Fereshteh Jaravandi, D.D.S.
4712 Jefferson Davis Hwy
Richmond, VA 23234
(804) 271-9828
Language(s): Arabic, Farsi, Spanish
HA
#34
Julius V. Morrison, D.D.S.
3501 Courthouse Rd
Richmond, VA 23236
(804) 745-9183
May 2014
HA
#36
Kenneth E Stoner DDS Family Dentistry
4106 A Meadowdale Blvd
Richmond, VA 23234
(804) 743-3490
Language(s): Russian
COLONIAL HEIGHTS
Colonial Heights
#20
Sam E English II DDS LLC
798 Southpark Blvd
Ste 26
Colonial Heights, VA 23834
(804) 520-1177
HANOVER
Mechanicsville
#1065
Amanjot Khara, D.D.S., P.C.
6372 Mechanicsville Tpke
Ste 106
Mechanicsville, VA 23111
(804) 559-5808
HA
#37532
K.J. Lee, D.M.D., PC
7347 Bell Creek Rd
Ste # 400
Mechanicsville, VA 23111
(804) 559-1016
Language(s): Korean
Extended Office Hours
#299 * HA
Morris L Jordan DDS
7239 Mechanicsville Trnpk.
Mechanicsville, VA 23111
(804) 730-9414
HA
#18
Sam E English II DDS Ltd
8220 Windmill Watch Dr
Mechanicsville, VA 23116
(804) 746-1085
HENRICO
Glen Allen
#300
HA
Bradley R Anderson DDS
11420 W Broad St
Glen Allen, VA 23060
(804) 360-3500
Language(s): Spanish
HA
#162167
Dr Antone C Exum and Associates
10124 W Broad St
Ste Q
Glen Allen, VA 23060
(804) 212-2501
HA
#37683
Nasser Damirchi D.D.S., P.C.
5243 Hickory Park Dr
Ste D
Glen Allen, VA 23059
(804) 270-5005
HA
#1522
Surya P. Dhakar, D.D.S., P.C.
4440 Springfield Rd
101
Glen Allen, VA 23060
(804) 217-9820
Language(s): Chinese, Hmong
Henrico
#2718
HA
Paul Da Cunha DMD PC
8503 Patterson Ave
Ste C
Henrico, VA 23229
(804) 262-9563
Richmond
#2542 * HA
Charles Hackett Jr DDS PC
1807 Libbie Ave
Ste 100
Richmond, VA 23226
(804) 288-9111
Language(s): Spanish
HA
#156583
Dhakar Family Dentistry PLC
1633 Williamsburg Rd
Richmond, VA 23231
(804) 447-4801
#1984
Garfield Family Dentistry
5500 Monument Ave
Ste G
Richmond, VA 23226
(804) 282-4646
HA
#14
George A Oley III DDS
9030 Three Chopt Rd
Ste A
Richmond, VA 23229
(804) 282-7011
Language(s): Arabic, Spanish
Extended Office Hours
** Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no
pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies).
1
#2614
HA
Great Expressions Dental Centers
4859 Finlay St
Richmond, VA 23231
(804) 222-6069
Language(s): Arabic, German
#47 * HA
Hudson & Hudson PC
1801 Raintree Dr
Ste A
Richmond, VA 23238
(804) 740-8320
#15
Raidah Hudson, D.D.S., P.C.
4374 S Laburnum Ave
Richmond, VA 23231
(804) 222-3135
Language(s): Arabic
#49
Ronald J Jessup DDS
1130 Wilkinson Rd
Richmond, VA 23227
(804) 261-4020
Extended Office Hours
HA
#87
William L. Newberry, D.D.S.
1717 Bellevue Ave
Imperial Plaza
Richmond, VA 23227
(804) 262-5445
HOPEWELL CITY
Hopewell
#19
HA
Sam E English II DDS Ltd
5303 Plaza Dr
Ste 103
Hopewell, VA 23860
(804) 458-5047
Language(s): Spanish
KING WILLIAM
West Point
#9
Sam E English II DDS Ltd
628 Main St
West Point, VA 23181
(804) 843-3233
PETERSBURG CITY
Petersburg
#98
HA
Charles F. Griffin, D.D.S.
3277 S Crater Rd
Ste C
Petersburg, VA 23805
(804) 733-8446
May 2014
RICHMOND CITY
Richmond
#10 *
Anthony J Puller DDS
7834 Forest Hill Ave
Ste 6
Richmond, VA 23225
(804) 272-0563
HA
#79793
Antone Exum DDS
505 W Leigh St
Ste 106
Richmond, VA 23220
(804) 648-2020
HA
#1699
Dentistry@VCU
520 N 12Th St
Richmond, VA 23298
(804) 828-3601
Language(s): Arabic
#38060
Grantham Family Dentistry
1122 N 25Th St
Ste E
Richmond, VA 23223
(804) 649-0240
#12 *
J David Lilly Jr DDS
7834 Forest Hill Ave
Richmond, VA 23225
(804) 320-0773
#64 * HA
John W. Jones, D.D.S.
1805 Monument Ave
Ste 501
Richmond, VA 23220
(804) 353-3009
HA
#59
Julius V. Morrison, D.D.S.
530 E Main St
Ste 400
Richmond, VA 23219
(804) 648-1305
HA
#1930
Vernon J. Harris East End Community
Health Center
719 N 25Th St
2Nd Floor
Richmond, VA 23223
(804) 253-1972
Language(s): Spanish
SPOTSYLVANIA
Fredericksburg
#147
Frank D. Romano, D.D.S.
1133 Heatherstone Dr
Fredericksburg, VA 22407
(540) 785-8525
Spotsylvania
#37958
Bright Now Dental
10454 Hill Top Plaza Way
Spotsylvania, VA 22553
(540) 891-6570
STAFFORD
Fredericksburg
#428
HA
Raymond C Haston Jr DDS PC
560 Celebrate Virginia Pkwy
107
Fredericksburg, VA 22406
(540) 286-1110
Stafford
#128646
HA
Aquia Dental Care
2712 Jefferson Davis Hwy
Ste 201
Stafford, VA 22554
(540) 720-8630
Language(s): Spanish
Extended Office Hours
HA
#40
Kenneth E Stoner DDS & Associates
4922 W Broad St
Westend
Richmond, VA 23230
(804) 282-4279
Language(s): Russian, Spanish
HA
#156
Bright Now Dental
392 Garrisonville Rd
Ste 205
Stafford, VA 22554
(540) 659-6816
#2669
Sam E English II DDS LLC
3500 Grove Ave
Richmond, VA 23221
(804) 358-0001
HA
#854
Elizabeth M Attreed DDS
2832 Jefferson Davis Hwy
Aquia Towne Center
Stafford, VA 22554
(540) 659-5161
115 South Union Street, Suite 300, Alexandria, VA 22314; DominionDental.com; (888) 681-5100 (Toll Free); (855) 485-0115 (Fax)
2