| Code | Procedure Description | Retail Fee* | Member Fee* | Member Savings* |
|---|---|---|---|---|
| D0140 | Limited Exam | $99 | $50 | 50% |
| D0150 | Comprehensive Exam | $114 | $57 | 50% |
| D0210 | Full-Mouth X-rays | $171 | $86 | 50% |
| D0274 | Bitewings - Four Images | $86 | $43 | 50% |
| D0330 | Panoramic X-Rays | $171 | $86 | 50% |
| D1110 | Adult Cleaning | $130 | $65 | 50% |
| D1120 | Child Cleaning | $99 | $50 | 50% |
| D1351 | Sealant - Per Tooth | $77 | $39 | 50% |
| D2330 | Composite - One Surface, Anterior | $175 | $175 | 25% |
| D2335 | Composite - Four/More Surfaces, Anterior | $337 | $337 | 25% |
| D2740 | Crown - Porcelain/Ceramic | $1,374 | $1,031 | 25% |
| D2750 | Crown - Porcelain/High Noble Metail | $1,352 | $1,014 | 25% |
| D2950 | Core Buildup | $327 | $246 | 25% |
| D3310 | Root Canal - Molar | $789 | $873 | 25% |
| D5110 | Complete Denture - Maxillary | $1,319 | $990 | 25% |
| D7140 | Simple Extraction | $171 | $129 | 25% |
| D7210 | Surgical Extraction | $286 | $215 | 25% |
| All Other Services | $TBD | $TBD | 20-50% |
*Member savings may vary by location. Please speak with your participating dental office prior to treatment.