SMILE. WE'VE GOT YOU COVERED.

Dental Benefits For Everyone.

Which plan is right for you?

Below you can compare monthly rates and coverage under the Discount, Select, Elite PPO and Elite ePPO. For more details, you can view a Complete List of Benefits for each plan at the bottom of the chart, including pediatric dental plans. The "Percentages" tab below shows how much each of the plans cover for each of the listed procedures. Click the "Copayments" tab to see a comparison that shows how much you would pay (in dollar amounts), for these procedures for each of these plans.

  Discount Select Plan Basic Elite PPO Basic
Benefit Features Plan Offers Plan Offers Plan Offers
Office Visit Charge $15 $10 None
Deductibles None None $50 per insured person
($150 family max)
Annual Maximum Limits  None None $1,000 per insured person
Lifetime Maximum Limits for Orthodontics None None N/A
Waiting Periods None None None
Claims Forms None None Yes
Must Use a Network Dentist Yes Yes No
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
We Cover1 We Cover1 We Cover2
(Yr. 1)
We Cover2
(Yr. 2)
We Cover2
(Yr. 3)
 I.  Preventive/Diagnostic Services (60% - 100%) (90% - 100%) (100%) (100%) (100%)
Oral Examination 100% 100% 100% 100% 100%
Bitewing X-Rays  60% 100% 100% 100% 100%
Cleaning for Adults 100% (1 per year) 90% 100% 100% 100%
Cleaning for Children 100% (1 per year) 90% 100% 100% 100%
Topical Fluoride - For Children 100% 100% 100% 100% 100%
 II. Basic Restorative Services (45% - 60%) (65% - 80%) (50%) (60%) (80%)
Full Mouth X-Rays 60% 80% 50% 60% 80%
Silver Filling (Two Surfaces) 45% 75% 50% 60% 80%
Composite Filling (Two Surfaces) 55% 65% 50% 60% 80%
 III. Major Restorative Services (40% - 50%) (55% - 70%) (15%) (25%) (50%)
Simple (Routine) Extraction 50% 60% 15% 25% 50%
Periodontal Scaling/Root Planing 45% 55% 15% 25% 50%
Perio Surgery (Gingivectomy/Gingivoplasty)  45% 55% 15% 25% 50%
Root Canal (Molar) 45% 70% 15% 25% 50%
Crown (Porcelain Fused to Metal) 40% 55% 15% 25% 50%
Denture (Complete Upper/Lower) 45% 65% 15% 25% 50%
 IV. Orthodontics
Children 45% 45% 0% 0% 0%
Adults 45% 45% 0% 0% 0%
Complete List of Benefits    Discount

Adult
Select Plan Basic

Pediatric
Select Plan Basic Kids

Adult
Elite PPO Basic

Pediatric
Elite PPO Basic Kids

 

Additional Plans 


 
Select Plan PremiumElite PPO Plus Elite PPO PremiumElite ePPO Basic
Benefit FeaturesPlan OffersPlan OffersPlan Offers  Plan Offers
Office Visit Charge$10NoneNoneNone
DeductiblesNone$50 per insured person$50 per insured person  $25 per insured person
Annual Maximum Limits None$750 per insured person  $1,500 per insured person  $1,500 per insured person
Lifetime Maximum Limits for OrthodonticsNoneNANANA
Waiting PeriodsNoneNone0/6/12None
Claims FormsNoneYesYesYes
Must Use a Network DentistYesNoNoYes
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
We Cover1We Cover
(In-Network | Out-of-Network)
We Cover
(In-Network | Out-of-Network) 
We Cover1
 I.  Preventive/Diagnostic Services(100%)(100% | 90%)(100% | 90%)   (100%)
Oral Examination100%100% | 90%100% | 90%    100%
Bitewing X-Rays 100%100% | 90%    100% | 90%   100%
Cleaning for Adults100%100% | 90%  100% | 90%   100%
Cleaning for Children100%100% | 90%  100% | 90%   100%
Topical Fluoride - For Children100%100% | 90%  100% | 90%   100%
 II. Basic Restorative Services(70%-80%)(50% | 40%)(80% | 70%)   (70%-85%)
Full Mouth X-Rays80%100% | 90%  (Class I)100% | 90%  (Class I)   100% (Class I)
Silver Filling (Two Surfaces)70%50% | 40%  80% | 70%   85%
Composite Filling (Two Surfaces)70%50% | 40%  80% | 70%   85%
 III. Major Restorative Services(55%-70%)(0% | 0%)(50% | 40%)   (45%-75%)
Simple (Routine) Extraction60%50% | 40%  (Class II)50% | 40% (Class II)      60%
Periodontal Scaling/Root Planing60%50% | 40%  (Class II)50% | 40%     70%
Perio Surgery (Gingivectomy/Gingivoplasty) 55%0% | 0%  50% | 40%     60%
Root Canal (Molar)70%0% | 0%  50% | 40%    50%
Crown (Porcelain Fused to Metal)60%0% | 0%  50% | 40%   60%
Denture (Complete Upper/Lower)70%0% | 0%  50% | 40%   75%
 IV. Orthodontics
Children45%0% | 0%  0% | 0%   0%
Adults45%0% | 0%  0% | 0%   0%
Complete List of Benefits   Adult
Select Plan Premium

Pediatric
Select Plan Premium Kids

Adult
Elite PPO Plus

Pediatric
Elite PPO Basic Kids

Adult
Elite PPO Premium

Pediatric

Elite PPO Premium Kids

Adult

Elite ePPO Basic

Pediatric
Elite PPO Basic Kids


1
Approximate percentage of coverage based on the Context4Healthcare's 80th percentile. Based on zip 223. A specific fee schedule applies and will be mailed with your membership card. Please see the Summary of Member Fees (Discount) or the Description of Member Copayments (Select Plan and Elite ePPO) inside the brochure for a sample of member fees. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
2 Year 1 benefits apply during the subscriber's first 12 months of continuous coverage. Year 2 benefits apply during the subscriber's second 12 months of continuous coverage and Year 3 benefits apply during the subscriber's third 12 months of continuous coverage.

 

Which plan is right for you?

Below you can compare monthly rates and coverage under the Discount, Select, Elite PPO and Elite ePPO. For more details, you can view a Complete List of Benefits for each plan at the bottom of the chart, including pediatric dental plans. The "Copayments" tab below shows how much you would pay (in dollar amounts), for these procedures for each of these plans.  Click the "Percentages" tab to see a comparison that shows how much each of the plans cover for each of the listed procedures.

  Discount Select Plan Basic Elite PPO Basic
Benefit Features Plan Offers Plan Offers Plan Offers
Office Visit Charge $15 $10 None
Deductibles None None $50 per insured person
($150 family max)
Annual Maximum Limits  None None $1,000 per insured person
Lifetime Maximum Limits for Orthodontics None None N/A
Waiting Periods None None None
Claims Forms None None Yes
Must Use a Network Dentist Yes Yes No
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
Average Cost
Without a Plan1
You Pay You Pay You Pay2
(Year 1)
You Pay2
(Year 2)
You Pay2
(Year 3)
 I.  Preventive/Diagnostic Services
Oral Examination $86 $0 $0 $0 $0 $0
Bitewing X-Rays  $40 $22 $0 $0 $0 $0
Cleaning for Adults $90 $0
(1 per year)
$13 $0 $0 $0
Cleaning for Children $65 $0
(1 per year)
$10 $0 $0 $0
Topical Fluoride - For Children $42 $0 $0 $0 $0 $0
 II. Basic Restorative Services
Full Mouth X-Rays $130 $66 $26 $100 $67 $33
Silver Filling (Two Surfaces) $151 $81 $51 $90 $60 $30
Composite Filling (Two Surfaces) $190 $97 $83 $128 $86 $43
 III. Major Restorative Services
Simple (Routine) Extraction $139 $81 $69 $143 $126 $84
Periodontal Scaling/Root Planing $247 $126 $109 $205 $181 $121
Perio Surgery (Gingivectomy/Gingivoplasty)  $676 $338 $279 $951 $839 $560
Root Canal (Molar) $897 $526 $512 $1,028 $907 $605
Crown (Porcelain Fused to Metal) $1,210 $644 $523 $887 $783 $522
Denture (Complete Upper/Lower) $1,493 $778 $697 $1,226 $1,082 $721
 IV. Orthodontics
Children $6,244 $3,422 $3,422 Not Covered Not Covered Not Covered
Adults $6,244 $3,658 $3,658 Not Covered Not Covered Not Covered
Complete List of Benefits    Discount

Adult
Select Plan Basic

Pediatric
Select Plan Basic Kids

Adult
Elite PPO Basic

Pediatric
Elite PPO Basic Kids

 

 

 

Additional Plans 

 Select Plan PremiumElite PPO PlusElite PPO PremiumElite ePPO Basic
Benefit FeaturesPlan OffersPlan OffersPlan OffersPlan Offers
Office Visit Charge$10None  None   None
DeductiblesNone  $50 per insured person$50 per insured person $25 per insured person
Annual Maximum Limits None  $750 per insured person $1,500 per insured person   $1,500 per insured person
Lifetime Maximum Limits for OrthodonticsNone  NANA NA
Waiting PeriodsNone  None0/6/12 None
Claims FormsNone  YesYes Yes
Must Use a Network DentistYesNoNo Yes
Benefit Coverage Examples
(See complete list of benefits for all procedures)  

Average Cost 
Without a Plan1
You PayYou Pay2
(In-Network | Out-of-Network) 
You Pay2
(In-Network | Out-of-Network)
You Pay
 I.  Preventive/Diagnostic Services
Oral Examination$86$0$0 | $0 $0 | $0 $0
Bitewing X-Rays $40$0$0 | $0    $0 | $0 $0
Cleaning for Adults$90$0$0 | $0   $0 | $0 $0
Cleaning for Children$65$0$0 | $0   $0 | $0 $0
Topical Fluoride - For Children$42$0$0 | $0   $0 | $0 $0
 II. Basic Restorative Services
Full Mouth X-Rays$130$26$0 | $0     $0 | $0$0
Silver Filling (Two Surfaces)$151$46$75 | $90 $30 | $45$30
Composite Filling (Two Surfaces)$190$76$95 | $114 $38 | $57$42
 III. Major Restorative Services
Simple (Routine) Extraction$139$63$69 | $83 $69 | $83$50
Periodontal Scaling/Root Planing$247$105$123 | $148 $123 | $148$97
Perio Surgery (Gingivectomy/Gingivoplasty) $676$265Not Covered  $338 | $405$198
Root Canal (Molar)$897$488Not Covered $448 | $538$780
Crown (Porcelain Fused to Metal)$1,210$495Not Covered  $605 | $ 726$520
Denture (Complete Upper/Lower)$1,493$664Not Covered  $746 | $895 $560
 IV. Orthodontics
Children$6,244$3,422Not Covered  Not CoveredNot Covered
Adults$6,244$3,658Not Covered  Not CoveredNot Covered
Complete List of Benefits   

Adult

Select Plan Premium 

Pediatric
Select Plan Premium Kids

 

Adult

Elite PPO Plus 

Pediatric
Elite PPO Basic Kids

 

Adult
Elite PPO Premium

Pediatric
Elite PPO Premium Kids

 

Adult
Elite ePPO Basic

Pediatric
Elite PPO Basic Kids

1 Average costs based on the Captiva Context Fee Schedule's 80th percentile for zip codes beginning with 223. 
2 Payment amounts are estimates based on the percentage covered in-network using the Captiva Context Fee Schedule's 80th percentile.