Savings Summary
Don’t let the high cost of dental care prevent you from taking care of your teeth. Maximize the value of membership with exclusive member discounts on most dental services.
| DESCRIPTION OF SERVICES | ||
|---|---|---|
| ADA Code | Diagnostic & Preventative | Member Pays |
| D0120 | Periodic Exam | NO CHARGE |
| D0140 | Limited Exam | NO CHARGE |
| D0150 | Comprehensive Exam | NO CHARGE |
| D0210 | Full Mouth X-Ray | NO CHARGE |
| D0274 | Bitewings - Four Films | NO CHARGE |
| D0330 | Panoramic X-Ray | NO CHARGE |
| D1110 | Adult Cleaning | NO CHARGE |
| D1120 | Child Cleaning | NO CHARGE |
| D1206 | Fluoride - With Varnish | $38.00 |
| D1351 | Sealant - Per Tooth | $51.00 |
| Restorative - Fillings Resin-Based Composite | ||
| D2330 | Composite Filling - One Surface, Anterior | $180.00 |
| D2332 | Composite Filling - Three Surface, Anterior | $240.00 |
| D2391 | Composite Filling - One Surface, Posterior | $180.00 |
| D2392 | Composite Filling - Two Surface, Posterior | $210.00 |
| D2393 | Composite Filling - Three Surface, Posterior | $240.00 |
| Restorative - Crowns | ||
| D2740 | Crown - Porcelain/Ceramic Substrate | $1050.00 |
| D2920 | Crown - Recementation | $107.00 |
| D2950 | Core Buildup | $150.00 |
| Periodontics | ||
| D4341 | Perio Scaling & Root Planing - 4+ Teeth (Per Quad) | $150.00 |
| D4910 | Periodontal Maintenance - Single Visit | $125.00 |
| Specialty | ||
| D6058 | Abutment Supported Crown Porc/Ceramic | $1238.00 |
| D6959 | Abutment Supported PFM Crown | $1288.00 |
| D7210 | Surgical Extraction | $242.00 |
| D8680 | Orthodontic Retainers | $500.00 |
| D8090 | Comprehensive Orthodontics - Adult | $3495.00 |
| Whitening | $75.00 |
*Member savings may vary by location. Free exams, cleanings, and x-rays limited to 2x per member/per annual membership term. Please speak with your participating provider for more information.