DIAGNOSTIC AND PREVENTIVE PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D0120 Periodic Oral Evaluation $71 NO CHARGE 100%
D0140 Limited Oral Evaluation - Problem Focused $105 NO CHARGE 100%
D0150 Comprehensive Oral Evaluation $122 NO CHARGE 100%
D0210 X-Rays - Intraoral Complete Series $187 NO CHARGE 100%
D0274 Bitewings - Four Images $92 NO CHARGE 100%
D0330 X-Rays - Panoramic $158 NO CHARGE 100%
D1110 Adult Cleaning $128 $64 50%
D1120 Child Cleaning $100 $50 50%
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per membership term.
BASIC, MAJOR AND OTHER PROCEDURES
Code Procedure Description Retail Fee* Member Fee* Member Savings*
D2330 Composite - One Surface, Anterior $238 $179 25%
D2331 Composite - Two Surfaces, Anterior $288 $216 25%
D2332 Composite - Three Surfaces, Anterior $354 $266 25%
D2335 Composite - Four/More Surfaces, Anterior $442 $332 25%
D2391 Composite - One Surface, Posterior $255 $191 25%
D2392 Composite - Two Surfaces, Posterior $326 $245 25%
D2393 Composite - Three Surfaces, Posterior $401 $301 25%
D2394 Composite - Four/More Surfaces, Posterior $480 $360 25%
D2720 Crown - Resin With High Noble Metal $1,606 $1,285 20%
D2740 Crown - Porcelain/Ceramic $1,606 $1,285 20%
D2750 Crown - Porcelain/High Noble Metal $1,587 $1,270 20%
D2950 Core Buildup $373 $298 20%
D3310 Endodontic Therapy - Anterior Tooth $1,067 $854 20%
D3320 Endodontic Therapy - Bicuspid Tooth $1,204 $963 20%
D3330 Endodontic Therapy - Molar Tooth $1,469 $1,174 20%
D5110 Complete Denture - Maxillary $2,453 $1,962 20%
D5120 Complete Denture - Mandibular $2,502 $2,002 20%
D5130 Immediate Denture - Maxillary $2,617 $2,094 20%
D5140 Immediate Denture - Mandibular $2,630 $2,104 20%
D7140 Extraction - Erupted Tooth/Exposed Root $262 $210 20%
*Member savings may vary by location. Free exams and x-rays limited to 2x per member/per membership term.

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