DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Oral Evaluation $40 NO CHARGE 100%
D0140 Limited Oral Evaluation - Problem Focused $30 NO CHARGE 100%
D0150 Comprehensive Oral Evaluation $60 NO CHARGE 100%
D0210 X-Rays - Intraoral Complete Series $90 NO CHARGE 100%
D0274 Bitewings - Four Images $50 NO CHARGE 100%
D0330 X-Rays - Panoramic $80 NO CHARGE 100%
D1110 Adult Cleaning $80 $72 10%
D1120 Child Cleaning $60 $54 10%
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.
BASIC, MAJOR AND OTHER PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D2330 Resin one surface Anterior $120 $108 10%
D2331 Resin two surface Anterior $140 $126 10%
D2332 Resin three surface Anterior $160 $144 10%
D2335 Resin four surface Anterior $180 $162 10%
D2391 Resin based one surface composite posterior $100 $90 10%
D2392 Resin based two surface composite posterior $120 $108 10%
D2393 Resin based three surface composite posterior $140 $126 10%
D2394 Resin based four surface composite posterior $160 $144 10%
D2740 Crown - Porcelain/Ceramic $900 $810 10%
D2750 Crown - Porcelain/High Noble Metal $800 $720 10%
D2950 Core Buildup, including any pins $130 $117 10%
D3310 Anterior final Restoration RCT $700 $630 10%
D3320 Bicuspid Final Restoration RCT $800 $720 10%
D3330 Molar Final Restoration RCT $900 $810 10%
D5110 Complete Upper $900 $810 10%
D5120 Complete Lower $900 $810 10%
D5130 Immediate Upper $1,100 $990 10%
D5140 Immediate Lower $1,100 $990 10%
D7140 Extration erupted tooth or exposed root (elevation/forcep removal) $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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