DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Exam $52 NO CHARGE 100%
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%
D1110 Adult Cleaning $95 $67 30%
D1120 Child Cleaning $73 $51 30%
*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 Composite - One Surface, Anterior $175 $131 25%
D2331 Composite - Two Surfaces, Anterior $212 $159 25%
D2332 Composite - Three Surfaces, Anterior $261 $196 25%
D2335 Composite - Four/More Surfaces, Anterior $326 $245 25%
D2391 Composite - One Surface, Posterior $188 $141 25%
D2392 Composite - Two Surfaces, Posterior $240 $180 25%
D2393 Composite - Three Surfaces, Posterior $295 $221 25%
D2394 Composite - Four/More Surfaces, Posterior $353 $265 25%
D2720 Crown - Resin With High Noble Metal $1,098 $878 20%
D2740 Crown - Porcelain/Ceramic $1,183 $946 20%
D2750 Crown - Porcelain/High Noble Metal $1,169 $935 20%
D2950 Core Buildup (Excluding Final Restoration) $274 $219 20%
D3310 Endodontic Therapy - Anterior Tooth $785 $589 25%
D3320 Endodontic Therapy - Bicuspid Tooth $886 $665 25%
D3330 Endodontic Therapy - Molar Tooth $1,082 $812 25%
D5110 Complete Denture - Maxillary $1,807 $1,446 20%
D5120 Complete Denture - Mandibular $1,843 $1,474 20%
D5130 Immediate Denture - Maxillary $1,927 $1,542 20%
D5140 Immediate Denture - Mandibular $1,937 $1,550 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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