|Code||Procedure Description||Retail Fee*||Member Fee*||Member Savings*|
|D0140||Limited Oral Evaluation||$80||NO CHARGE||100%|
|D0150||Comprehensive Oral Evaluation||$100||NO CHARGE||100%|
|D0210||X-Rays - Intraoral Complete Series||$100||NO CHARGE||100%|
|D0274||Bitewings - Four Images||$100||NO CHARGE||100%|
|D0330||X-Rays - Panoramic||$100||NO CHARGE||100%|
|D2330||Composite - One Surface, Anterior||$120||$108||10%|
|D2335||Composite - Four/More Surfaces, Anterior||$180||$162||10%|
|D2740||Crown - Porcelain/Ceramic||$900||$810||10%|
|D2750||Crown - Porcelain/High Noble Metail||$800||$720||10%|
|D5110||Complete Denture - Maxillary||$900||$810||10%|
|D7140||Extraction - Erupted Tooth/Exposed Root||$150||$135||10%|
|*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.|
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