DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Exams $46 FREE 100%
D0140 Limited Exams $72 FREE 100%
D0150 Comprehensive Exams $93 FREE 100%
D0210 X-Rays - Intraoral Complete Series $128 FREE 100%
D0274 Bitewings - Four Images $69 FREE 100%
D0330 X-Rays - Panoramic $122 FREE 100%
D1110 Adult Cleanings $98 $49 50%
D1120 Child Cleanings $72 $36 50%
Any current dental procedures not listed are 20-50% off retail fee(s)
BASIC, MAJOR AND OTHER PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D2330 Composites - One Surface, Anterior $161 $120 25%
D2331 Composites - Two Surfaces, Anterior $225 $168 25%
D2332 Composites - Three Surfaces, Anterior $277 $207 25%
D2335 Composites - Four/More Surfaces, Anterior $347 $260 25%
D2391 Composites - One Surface, Posterior $199 $149 25%
D2392 Composites - Two Surfaces, Posterior $256 $192 25%
D2393 Composites - Three Surfaces, Posterior $317 $237 25%
D2394 Composites - Four/More Surfaces, Posterior $379 $284 25%
D2720 Crowns - Resin With High Noble Metal $1,201 $900 25%
D2740 Crowns - Porcelain/Ceramic $1,264 $948 25%
D2750 Crowns - 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 Dentures - Maxillary $1,359 $1,087 20%
D5120 Complete Dentures - Mandibular $1,359 $1,087 20%
D5130 Immediate Dentures - Maxillary $1,648 $1,318 20%
D5140 Immediate Dentures - Mandibular $1,648 $1,318 20%
D7140 Extractions - Erupted Tooth/Exposed Root $196 $147 25%
Any current dental procedures not listed are 20-50% off retail fee(s)

*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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