| Code | Procedure Description | Retail Fee* | Member Fee* | Member Savings* |
|---|---|---|---|---|
| D0140 | Limited Exam | $111 | $50 | 55% |
| D0150 | Comprehensive Exam | $118 | $59 | 50% |
| D0210 | Full-Mouth X-rays | $212 | $74 | 65% |
| D0274 | Bitewings - Four Images | $90 | $35 | 61% |
| D0431 | Oral Cancer Screenings | $50 | NO CHARGE | 100% |
| D1110 | Adult Cleaning | $125 | $65 | 48% |
| D1120 | Child Cleaning | $110 | $54 | 51% |
| D1206 | Fluoride - With Varnish | $32 | $25 | 29% |
| D1351 | Sealant - Per Tooth | $85 | $45 | 47% |
| D2330 | Composite - One Surface, Anterior | $218 | $129 | 41% |
| D2740 | Crown - Porcelain/Ceramic | $1,143 | $869 | 34% |
| D4910 | Periodontal Maintenance | $187 | $99 | 47% |
| D5110 | Complete Denture - Maxillary | $2,000 | $999 | 50% |
| D7140 | Simple Extraction | $185 | $89 | 52% |
| TBD | Most Other Services | $TBD | $TBD | 20-65% |
* Member savings may vary by location. Please speak with your participating dental office prior to treatment.