DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Oral Evaluation $40 FREE 100%
D0140 Limited Oral Evaluation - Problem Focused $30 FREE 100%
D0150 Comprehensive Oral Evaluation $60 FREE 100%
D0210 X-Rays - Intraoral Complete Series $90 FREE 100%
D0274 Bitewings - Four Images $50 FREE 100%
D0330 X-Rays - Panoramic $80 FREE 100%
D1110 Adult Cleaning $80 $72 10%
D1120 Child Cleaning $60 $54 10%
Note: any current dental services not listed above are discounted 10% off your participating dental office's retail fees.
BASIC, MAJOR AND OTHER PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D2330 Resin one surface Anterior $120 $108.00 10%
D2331 Resin two surface Anterior $140 $126.00 10%
D2332 Resin three surface Anterior $160 $144.00 10%
D2335 Resin four surface Anterior $180 $162.00 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%
Note: any current dental services not listed above are discounted 10% off your participating dental office's retail fees.

*This is just an example of savings. Member savings is defined as the amount members pay less participating offices’ retail fees typically charged to self-pay patients for services rendered. Free exams and x-rays limited to 2x per member/per annual membership term. Please speak with your participating office prior to beginning treatment.

a�?Since Medicare doesn't cover dental we were looking for an affordable solution to save us money at our dentist. Fresh Dental Plan is perfect for seniors like us that don't have dental insurance. We love that Fresh Dental Plan keeps it simple with no waiting periods, maximums or exclusions.a�? Henry & Lachelle
a�?Our employer offered dental insurance was expensive and lacked value. Our family needed a plan that's affordable, easy-to-use and has significant real dollar savings. In exchange for a low annual membership fee, Fresh Dental Plan saves us hundreds of dollars each time we visit the dentist.a�? Margaret & Rick