DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Exam $46 FREE 100%
D0140 Limited Exam $72 FREE 100%
D0150 Comprehensive Exam $93 FREE 100%
D0210 Full-Mouth X-Rays $128 FREE 100%
D0274 Bitewings - Four Images $69 FREE 100%
D0330 X-Rays - Panoramic $122 FREE 100%
D1110 Adult Cleaning $98 $49 50%
D1120 Child Cleaning $72 $36 50%
Note: any current dental services not listed above are discounted 20-50% off your participating dental office's retail fees.
BASIC, MAJOR AND OTHER PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D2330 Composite - One Surface, Anterior $161 $120 25%
D2331 Composite - Two Surfaces, Anterior $225 $168 25%
D2332 Composite - Three Surfaces, Anterior $277 $207 25%
D2335 Composite - Four/More Surfaces, Anterior $347 $260 25%
D2391 Composite - One Surface, Posterior $199 $149 25%
D2392 Composite - Two Surfaces, Posterior $256 $192 25%
D2393 Composite - Three Surfaces, Posterior $317 $237 25%
D2394 Composite - Four/More Surfaces, Posterior $379 $284 25%
D2720 Crown - Resin With High Noble Metal $1,201 $900 25%
D2740 Crown - Porcelain/Ceramic $1,264 $948 25%
D2750 Crown - Porcelain/High Noble Metal $1,266 $949 25%
D2950 Core Buildup $297 $222 25%
D3310 Endodontic Therapy - Anterior Tooth $759 $569 25%
D3320 Endodontic Therapy - Bicuspid Tooth $947 $710 25%
D3330 Endodontic Therapy - Molar Tooth $1,168 $875 25%
D5110 Complete Denture - Maxillary $1,359 $1,087 20%
D5120 Complete Denture - Mandibular $1,359 $1,087 20%
D5130 Immediate Denture - Maxillary $1,648 $1,318 20%
D5140 Immediate Denture - Mandibular $1,648 $1,318 20%
D7140 Simple Extraction $196 $147 25%
Note: any current dental services not listed above are discounted 20-50% off your participating dental office's retail fees.

*Free exams and x-rays limited to 2x per member/per annual membership term. Member savings is defined as the amount members pay less participating offices’ normal retail fees typically charged to self-pay patients for dental services rendered. Exact member savings may vary by location. Please speak with your participating office prior to treatment.

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