|Code||Procedure Description||Retail Fee*||Member Fee*||Member Savings*|
|D0140||Limited Exam||$52||NO CHARGE||100%|
|D0150||Comprehensive Exam||$90||NO CHARGE||100%|
|D0210||Full Mouth X-Rays||$138||NO CHARGE||100%|
|D0274||Bitewings - Four Images||$68||NO CHARGE||100%|
|D0330||Panoramic X-Rays||$117||NO CHARGE||100%|
|D2330||Composite - One Surface, Anterior||$175||$131||25%|
|D2335||Composite - Four/More Surfaces, Anterior||$353||$265||25%|
|D2740||Crown - Porcelain/Ceramic||$1,183||$946||20%|
|D2750||Crown - Porcelain/High Noble Metal||$1,169||$935||20%|
|D5110||Complete Denture - Maxillary||$1,807||$1,446||20%|
|D7140||Extraction - Erupted Tooth/Exposed Root||$193||$154||20%|
|*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per annual membership term.|
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