Providing Individuals & Families With Affordable Dental Care Since 2016

Our members enjoy savings up to 50% on all procedures at over 120 offices nationwide. Smile Care Savings Plan keeps it simple by featuring no waiting periods, exclusions, or maximums, and transparent 10-50% member savings on all preventive, basic, major, cosmetic, orthodontic and specialty dentistry.

Select a participating office to view exact member savings:

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DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Oral Evaluation	$61.00	$30.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$89.00	$FREE**	100%
D0150	Comprehensive Oral Evaluation	$106.00	$FREE**	100%
D0210	Intraoral - Complete Series	$154.00	$FREE**	100%
D0220	Intraoral - Peripical First Image	$33.00	$FREE**	100%
D0274	Bitewings - Four Images	$76.00	$FREE**	100%
D0330	Panoramic Image	$135.00	$FREE**	100%
D1110	Prophylaxis - Adult	$110.00	$55.00	50%
D1120	Prophylaxis - Child	$83.00	$41.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$46.00	$20.00	57%
D1351	Sealant - Per Tooth	$66.00	$25.00	62%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$172.00	$129.00	25%
D2150	Amalgam - Two Surfaces	$205.00	$153.00	25%
D2160	Amalgam - Three Surfures	$251.00	$188.00	25%
D2330	Composite - One Surface, Anterior	$191.00	$101.00	47%
D2331	Composite - Two Surfaces, Anterior	$231.00	$121.00	48%
D2332	Composite - Three Surfaces, Anterior	$288.00	$144.00	50%
D2335	Composite - Four/More Surfaces, Anterior	$355.00	$204.00	43%
D2391	Composite - One Surface, Posterior	$207.00	$115.00	44%
D2392	Composite - Two Surfaces, Posterior	$269.00	$145.00	46%
D2393	Composite - Three Surfaces, Posterior	$333.00	$183.00	45%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,283.00	$767.00	40%
D2750	Crown - Porcelain/High Noble Metal	$1,295.00	$767.00	41%
D2751	Crown - Porcelain/Base Metal	$1,184.00	$888.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,223.00	$917.00	25%
D2950	Core Buildup, Including Any Pins When Required	$319.00	$150.00	53%
D2952	Post And Core, Indirectly Fabricated	$471.00	$353.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$887.00	$580.00	35%
D3320	Endodontic Therapy, Bicuspid Tooth	$998.00	$760.00	24%
D3330	Endodontic Therapy, Molar Tooth	$1,174.00	$880.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$301.00	$150.00	50%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$219.00	$115.00	47%
D4381	Localized Delivery Of Antimicrobial Agents	$73.00	$35.00	52%
D4910	Periodontal Maintenance	$160.00	$104.00	35%
D5213	Maxillary Partial - Cast Metal	$2,058.00	$1,058.00	49%
D6010	Surgical Placement Of Endosteal Implant	$2,332.00	$1,637.00	30%
D6057	Custom Fabricated Abutment	$981.00	$784.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,523.00	$1,218.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,407.00	$1,125.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,831.00	$888.00	52%
D5120	Complete Denture - Mandibular	$1,831.00	$888.00	52%
D5730	Reline Denture - Maxillary (Chairside)	$393.00	$190.00	52%
D5740	Reline Partial - Maxillary (Chairside)	$393.00	$190.00	52%
D5750	Reline Denture - Maxillary (Lab)	$510.00	$251.00	51%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,370.00	$767.00	44%
D6751	Abutment - Porcelain/Base Metal	$1,184.00	$888.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,223.00	$917.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$203.00	$125.00	38%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$67.00	$33.00	51%
D0140	Limited Oral Evaluation	$98.00	$49.00	50%
D0150	Comprehensive Oral Evaluation	$128.00	$64.00	50%
D0210	X-Rays intraoral complete series	$176.00	$88.00	50%
D0220	X-Rays Intraoral periapical first film	$39.00	$19.00	51%
D0274	X-rays bitewings four films	$83.00	$41.00	51%
D1110	Prophylaxis Adult	$130.00	$65.00	50%
D1120	Prophylaxis Child	$100.00	$50.00	50%
D1208	Topical application of flouride-excluding varnish	$55.00	$27.00	51%
D1351	Sealant per tooth	$71.00	$35.00	51%
D2950	Core Buildup, including any pins	$340.00	$255.00	25%
D2952	Cast Post and core in add. To crown indirectly fabricated	$522.00	$391.00	25%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D0330	X-rays panoramic	$167.00	$83.00	50%
D2330	Resin one surface Anterior	$219.00	$164.00	25%
D2331	Resin two surface Anterior	$264.00	$198.00	25%
D2332	Resin three sufarce Anterior	$325.00	$243.00	25%
D2391	Resin based one surface composite posterior	$234.00	$175.00	25%
D2392	Resin based two surface conposite posterior	$295.00	$221.00	25%
D2393	Resin based three surface conposite posterior	$365.00	$273.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown porcelain Ceramic	$1,513.00	$1,134.00	25%
D2750	Crown porcelain fused to high noble	$1,433.00	$1,074.00	25%
D2751	Crown porcelain fused to predominantly base	$1,365.00	$1,023.00	25%
D2752	Crown porcelain fused to noble metal	$1,403.00	$1,052.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,511.00	$2,008.00	20%
D6057	Custom Fabricated Abutment	$1,150.00	$920.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,767.00	$1,413.00	20%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Anterior final Restoration RCT	$1,008.00	$756.00	25%
D3320	Bicuspid Final Restoration RCT	$1,157.00	$867.00	25%
D3330	Molar Final Restoration RCT	$1,407.00	$1,055.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Periodontal scaling and root planning	$358.00	$268.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$246.00	$184.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$181.00	$135.00	25%
D4910	Periodontal Maintenancce Procedure	$173.00	$129.00	25%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Upper	$2,254.00	$1,690.00	25%
D5120	Complete Lower	$2,266.00	$1,699.00	25%
D5213	Maxillary Partial-Cast Metal	$2,276.00	$1,707.00	25%
D5510	Repair broken complete denture	$293.00	$219.00	25%
D5730	Reline Complete Upper Denture	$484.00	$363.00	25%
D5740	Reline Upper Partial Denture	$466.00	$349.00	25%
D5750	Reline Complete Upper denture	$598.00	$448.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extration erupted tooth or exposed root (elevation/forcep removal)	$248.00	$186.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$45.00	$40.00	11%
D0140	Limited Oral Evaluation, Problem Focused	$66.00	$59.00	11%
D0150	Comprehensive Oral Evaluation	$71.00	$63.00	11%
D0210	Intraoral - Complete Series	$121.00	$108.00	11%
D0220	Intraoral - Peripical First Image	$26.00	$23.00	12%
D0274	Bitewings - Four Images	$60.00	$54.00	10%
D0330	Panoramic Image	$107.00	$96.00	10%
D1110	Prophylaxis - Adult	$80.00	$72.00	10%
D1120	Prophylaxis - Child	$60.00	$54.00	10%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$34.00	$30.00	12%
D1351	Sealant - Per Tooth	$48.00	$43.00	10%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$134.00	$120.00	10%
D2150	Amalgam - Two Surfaces	$158.00	$142.00	10%
D2160	Amalgam - Three Surfures	$180.00	$162.00	10%
D2330	Composite - One Surface, Anterior	$143.00	$128.00	10%
D2331	Composite - Two Surfaces, Anterior	$172.00	$154.00	10%
D2332	Composite - Three Surfaces, Anterior	$204.00	$183.00	10%
D2335	Composite - Four/More Surfaces, Anterior	$251.00	$225.00	10%
D2391	Composite - One Surface, Posterior	$151.00	$135.00	11%
D2392	Composite - Two Surfaces, Posterior	$191.00	$171.00	10%
D2393	Composite - Three Surfaces, Posterior	$231.00	$207.00	10%

CROWNS
code	Description	retail Fee*	member pays	savings*

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$693.00	$623.00	10%
D3320	Endodontic Therapy, Bicuspid Tooth	$798.00	$718.00	10%
D3330	Endodontic Therapy, Molar Tooth	$956.00	$860.00	10%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$145.00	$130.00	10%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$59.00	$29.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$89.00	$44.00	51%
D0150	Comprehensive Oral Evaluation	$102.00	$51.00	50%
D0210	Intraoral - Complete Series	$154.00	$77.00	50%
D0220	Intraoral - Peripical First Image	$36.00	$18.00	50%
D0274	Bitewings - Four Images	$77.00	$38.00	51%
D0330	Panoramic Image	$133.00	$66.00	50%
D1110	Prophylaxis - Adult	$107.00	$53.00	50%
D1120	Prophylaxis - Child	$81.00	$40.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$45.00	$22.00	51%
D1351	Sealant - Per Tooth	$65.00	$32.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$172.00	$129.00	25%
D2150	Amalgam - Two Surfaces	$215.00	$161.00	25%
D2160	Amalgam - Three Surfures	$263.00	$197.00	25%
D2330	Composite - One Surface, Anterior	$200.00	$150.00	25%
D2331	Composite - Two Surfaces, Anterior	$240.00	$180.00	25%
D2332	Composite - Three Surfaces, Anterior	$295.00	$221.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$368.00	$276.00	25%
D2391	Composite - One Surface, Posterior	$213.00	$159.00	25%
D2392	Composite - Two Surfaces, Posterior	$274.00	$205.00	25%
D2393	Composite - Three Surfaces, Posterior	$337.00	$252.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,328.00	$996.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,329.00	$996.00	25%
D2751	Crown - Porcelain/Base Metal	$1,244.00	$933.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,277.00	$957.00	25%
D2950	Core Buildup, Including Any Pins When Required	$317.00	$237.00	25%
D2952	Post And Core, Indirectly Fabricated	$486.00	$364.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$875.00	$656.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$996.00	$747.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,226.00	$919.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$300.00	$225.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$221.00	$165.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$169.00	$126.00	25%
D4910	Periodontal Maintenance	$161.00	$120.00	25%
D5213	Maxillary Partial - Cast Metal	$2,117.00	$1,587.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,272.00	$1,817.00	20%
D6057	Custom Fabricated Abutment	$1,073.00	$858.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,645.00	$1,316.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,635.00	$1,308.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,889.00	$1,416.00	25%
D5120	Complete Denture - Mandibular	$1,889.00	$1,416.00	25%
D5510	Repair Broken Complete Denture	$258.00	$193.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$450.00	$337.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$435.00	$326.00	25%
D5750	Reline Denture - Maxillary (Lab)	$557.00	$417.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,363.00	$1,022.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,233.00	$924.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,277.00	$957.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$209.00	$156.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$55.00	$27.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$94.00	$47.00	50%
D0150	Comprehensive Oral Evaluation	$96.00	$48.00	50%
D0210	Intraoral - Complete Series	$141.00	$70.00	50%
D0220	Intraoral - Peripical First Image	$31.00	$15.00	52%
D0274	Bitewings - Four Images	$70.00	$35.00	50%
D0330	Panoramic Image	$120.00	$60.00	50%
D1110	Prophylaxis - Adult	$101.00	$50.00	50%
D1120	Prophylaxis - Child	$84.00	$42.00	50%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$31.00	$15.00	52%
D1351	Sealant - Per Tooth	$60.00	$30.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2330	Composite - One Surface, Anterior	$191.00	$143.00	25%
D2331	Composite - Two Surfaces, Anterior	$241.00	$180.00	25%
D2332	Composite - Three Surfaces, Anterior	$292.00	$219.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$356.00	$267.00	25%
D2391	Composite - One Surface, Posterior	$198.00	$148.00	25%
D2392	Composite - Two Surfaces, Posterior	$271.00	$203.00	25%
D2393	Composite - Three Surfaces, Posterior	$336.00	$252.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,387.00	$1,040.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,387.00	$1,040.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,387.00	$1,040.00	25%
D2950	Core Buildup, Including Any Pins When Required	$302.00	$226.00	25%
D2952	Post And Core, Indirectly Fabricated	$473.00	$354.00	25%
D2950	Core Buildup, Including Any Pins When Required	$302.00	$226.00	25%
D2952	Post And Core, Indirectly Fabricated	$473.00	$354.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$808.00	$606.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$932.00	$699.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,111.00	$833.00	25%
D3310	Endodontic Therapy, Anterior Tooth	$808.00	$606.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$932.00	$699.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,111.00	$833.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$277.00	$207.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$200.00	$150.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$202.00	$151.00	25%
D4910	Periodontal Maintenance	$154.00	$115.00	25%
D5213	Maxillary Partial - Cast Metal	$2,200.00	$1,650.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,268.00	$1,814.00	20%
D6057	Custom Fabricated Abutment	$1,126.00	$900.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,387.00	$1,109.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,387.00	$1,109.00	20%
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$277.00	$207.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$200.00	$150.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$202.00	$151.00	25%
D4910	Periodontal Maintenance	$154.00	$115.00	25%
D5213	Maxillary Partial - Cast Metal	$2,200.00	$1,650.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,268.00	$1,814.00	20%
D6057	Custom Fabricated Abutment	$1,126.00	$900.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,387.00	$1,109.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,387.00	$1,109.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$2,200.00	$1,650.00	25%
D5120	Complete Denture - Mandibular	$2,200.00	$1,650.00	25%
D5510	Repair Broken Complete Denture	$234.00	$175.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$399.00	$299.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$385.00	$288.00	25%
D5750	Reline Denture - Maxillary (Lab)	$523.00	$392.00	25%
D5110	Complete Denture - Maxillary	$2,200.00	$1,650.00	25%
D5120	Complete Denture - Mandibular	$2,200.00	$1,650.00	25%
D5510	Repair Broken Complete Denture	$234.00	$175.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$399.00	$299.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$385.00	$288.00	25%
D5750	Reline Denture - Maxillary (Lab)	$523.00	$392.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,387.00	$1,040.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,387.00	$1,040.00	25%
D6750	Abutment - Porcelain/High Noble Metal	$1,387.00	$1,040.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,387.00	$1,040.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$190.00	$142.00	25%
D7140	Extraction, Erupted Tooth/Exposed Root	$190.00	$142.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$25.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$90.00	$45.00	50%
D0210	Intraoral - Complete Series	$133.00	$66.00	50%
D0220	Intraoral - Peripical First Image	$29.00	$14.00	52%
D0274	Bitewings - Four Images	$66.00	$33.00	50%
D0330	Panoramic Image	$113.00	$56.00	50%
D1110	Prophylaxis - Adult	$92.00	$46.00	50%
D1120	Prophylaxis - Child	$67.00	$33.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$39.00	$19.00	51%
D1351	Sealant - Per Tooth	$57.00	$28.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$155.00	$116.00	25%
D2150	Amalgam - Two Surfaces	$195.00	$146.00	25%
D2160	Amalgam - Three Surfures	$239.00	$179.00	25%
D2330	Composite - One Surface, Anterior	$171.00	$128.00	25%
D2331	Composite - Two Surfaces, Anterior	$209.00	$156.00	25%
D2332	Composite - Three Surfaces, Anterior	$257.00	$192.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$316.00	$237.00	25%
D2391	Composite - One Surface, Posterior	$184.00	$138.00	25%
D2392	Composite - Two Surfaces, Posterior	$235.00	$176.00	25%
D2393	Composite - Three Surfaces, Posterior	$292.00	$219.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,168.00	$876.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,146.00	$859.00	25%
D2751	Crown - Porcelain/Base Metal	$1,066.00	$799.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,090.00	$817.00	25%
D2950	Core Buildup, Including Any Pins When Required	$275.00	$206.00	25%
D2952	Post And Core, Indirectly Fabricated	$428.00	$321.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$767.00	$575.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$869.00	$651.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,054.00	$790.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$257.00	$192.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$187.00	$140.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$140.00	$105.00	25%
D4910	Periodontal Maintenance	$141.00	$105.00	26%
D5213	Maxillary Partial - Cast Metal	$1,820.00	$1,365.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,985.00	$1,588.00	20%
D6057	Custom Fabricated Abutment	$935.00	$748.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,510.00	$1,208.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,426.00	$1,140.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,776.00	$1,332.00	25%
D5120	Complete Denture - Mandibular	$1,789.00	$1,341.00	25%
D5510	Repair Broken Complete Denture	$222.00	$166.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$379.00	$284.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$365.00	$273.00	25%
D5750	Reline Denture - Maxillary (Lab)	$474.00	$355.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,147.00	$860.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,101.00	$825.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,142.00	$856.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$181.00	$135.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$66.00	$33.00	50%
D0140	Limited Oral Evaluation, Problem Focused	$99.00	$49.00	51%
D0150	Comprehensive Oral Evaluation	$113.00	$56.00	50%
D0210	Intraoral - Complete Series	$171.00	$85.00	50%
D0220	Intraoral - Peripical First Image	$40.00	$20.00	50%
D0274	Bitewings - Four Images	$85.00	$42.00	51%
D0330	Panoramic Image	$147.00	$73.00	50%
D1110	Prophylaxis - Adult	$119.00	$59.00	50%
D1120	Prophylaxis - Child	$89.00	$44.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$49.00	$24.00	51%
D1351	Sealant - Per Tooth	$72.00	$36.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$191.00	$114.00	40%
D2150	Amalgam - Two Surfaces	$239.00	$143.00	40%
D2160	Amalgam - Three Surfures	$291.00	$174.00	40%
D2330	Composite - One Surface, Anterior	$221.00	$132.00	40%
D2331	Composite - Two Surfaces, Anterior	$266.00	$159.00	40%
D2332	Composite - Three Surfaces, Anterior	$328.00	$196.00	40%
D2335	Composite - Four/More Surfaces, Anterior	$407.00	$244.00	40%
D2391	Composite - One Surface, Posterior	$236.00	$141.00	40%
D2392	Composite - Two Surfaces, Posterior	$303.00	$181.00	40%
D2393	Composite - Three Surfaces, Posterior	$374.00	$224.00	40%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,472.00	$883.00	40%
D2750	Crown - Porcelain/High Noble Metal	$1,473.00	$883.00	40%
D2751	Crown - Porcelain/Base Metal	$1,380.00	$828.00	40%
D2752	Crown - Porcelain/Noble Metal	$1,415.00	$849.00	40%
D2950	Core Buildup, Including Any Pins When Required	$351.00	$210.00	40%
D2952	Post And Core, Indirectly Fabricated	$539.00	$323.00	40%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$969.00	$581.00	40%
D3320	Endodontic Therapy, Bicuspid Tooth	$1,105.00	$663.00	40%
D3330	Endodontic Therapy, Molar Tooth	$1,359.00	$815.00	40%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$333.00	$199.00	40%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$245.00	$147.00	40%
D4381	Localized Delivery Of Antimicrobial Agents	$187.00	$112.00	40%
D4910	Periodontal Maintenance	$177.00	$106.00	40%
D5213	Maxillary Partial - Cast Metal	$2,347.00	$1,408.00	40%
D6010	Surgical Placement Of Endosteal Implant	$2,519.00	$1,511.00	40%
D6057	Custom Fabricated Abutment	$1,190.00	$714.00	40%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,824.00	$1,094.00	40%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,812.00	$1,087.00	40%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$2,290.00	$1,374.00	40%
D5120	Complete Denture - Mandibular	$2,293.00	$1,375.00	40%
D5510	Repair Broken Complete Denture	$287.00	$172.00	40%
D5730	Reline Denture - Maxillary (Chairside)	$500.00	$300.00	40%
D5740	Reline Partial - Maxillary (Chairside)	$481.00	$288.00	40%
D5750	Reline Denture - Maxillary (Lab)	$617.00	$370.00	40%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,511.00	$906.00	40%
D6751	Abutment - Porcelain/Base Metal	$1,366.00	$819.00	40%
D6752	Abutment - Porcelain/Noble Metal	$1,415.00	$849.00	40%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$232.00	$139.00	40%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$25.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$90.00	$45.00	50%
D0210	Intraoral - Complete Series	$133.00	$66.00	50%
D0220	Intraoral - Peripical First Image	$36.00	$18.00	50%
D0274	Bitewings - Four Images	$66.00	$33.00	50%
D0330	Panoramic Image	$112.00	$56.00	50%
D1110	Prophylaxis - Adult	$95.00	$47.00	51%
D1120	Prophylaxis - Child	$68.00	$34.00	50%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$44.00	$22.00	50%
D1351	Sealant - Per Tooth	$56.00	$28.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$145.00	$108.00	26%
D2150	Amalgam - Two Surfaces	$182.00	$136.00	25%
D2160	Amalgam - Three Surfures	$222.00	$166.00	25%
D2330	Composite - One Surface, Anterior	$166.00	$124.00	25%
D2331	Composite - Two Surfaces, Anterior	$206.00	$154.00	25%
D2332	Composite - Three Surfaces, Anterior	$255.00	$191.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$321.00	$240.00	25%
D2391	Composite - One Surface, Posterior	$184.00	$138.00	25%
D2392	Composite - Two Surfaces, Posterior	$238.00	$178.00	25%
D2393	Composite - Three Surfaces, Posterior	$294.00	$220.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,171.00	$878.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,149.00	$861.00	25%
D2751	Crown - Porcelain/Base Metal	$1,059.00	$794.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,084.00	$813.00	25%
D2950	Core Buildup, Including Any Pins When Required	$280.00	$210.00	25%
D2952	Post And Core, Indirectly Fabricated	$429.00	$321.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$764.00	$573.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$874.00	$655.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,047.00	$785.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$264.00	$198.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$191.00	$143.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$147.00	$110.00	25%
D4910	Periodontal Maintenance	$141.00	$105.00	26%
D5213	Maxillary Partial - Cast Metal	$1,932.00	$1,449.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,835.00	$1,468.00	20%
D6057	Custom Fabricated Abutment	$958.00	$766.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,477.00	$1,181.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,386.00	$1,108.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,843.00	$1,382.00	25%
D5120	Complete Denture - Mandibular	$1,843.00	$1,382.00	25%
D5510	Repair Broken Complete Denture	$216.00	$162.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$382.00	$286.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$373.00	$279.00	25%
D5750	Reline Denture - Maxillary (Lab)	$484.00	$363.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,151.00	$863.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,083.00	$812.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,092.00	$819.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$181.00	$135.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$58.00	$29.00	50%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$89.00	$44.00	51%
D0210	Intraoral - Complete Series	$133.00	$66.00	50%
D0220	Intraoral - Peripical First Image	$35.00	$17.00	51%
D0274	Bitewings - Four Images	$75.00	$37.00	51%
D0330	Panoramic Image	$112.00	$56.00	50%
D1110	Prophylaxis - Adult	$105.00	$52.00	50%
D5750	Reline Denture - Maxillary (Lab)	$545.00	$408.00	25%
D7140	Extraction, Erupted Tooth/Exposed Root	$180.00	$135.00	25%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*

CROWNS
code	Description	retail Fee*	member pays	savings*
D1120	Prophylaxis - Child	$79.00	$39.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$44.00	$22.00	50%
D1351	Sealant - Per Tooth	$64.00	$32.00	50%
D2140	Amalgam - One Surface	$169.00	$126.00	25%
D2150	Amalgam - Two Surfaces	$211.00	$158.00	25%
D2160	Amalgam - Three Surfures	$257.00	$192.00	25%
D2330	Composite - One Surface, Anterior	$195.00	$146.00	25%
D2331	Composite - Two Surfaces, Anterior	$235.00	$176.00	25%
D2332	Composite - Three Surfaces, Anterior	$289.00	$216.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$360.00	$270.00	25%
D2391	Composite - One Surface, Posterior	$209.00	$156.00	25%
D2392	Composite - Two Surfaces, Posterior	$268.00	$201.00	25%
D2393	Composite - Three Surfaces, Posterior	$330.00	$247.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,299.00	$974.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,149.00	$861.00	25%
D2751	Crown - Porcelain/Base Metal	$1,059.00	$794.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,250.00	$937.00	25%
D2950	Core Buildup, Including Any Pins When Required	$310.00	$232.00	25%
D2952	Post And Core, Indirectly Fabricated	$476.00	$357.00	25%
D3310	Endodontic Therapy, Anterior Tooth	$764.00	$573.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$974.00	$730.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,199.00	$899.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$294.00	$220.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$216.00	$162.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$165.00	$123.00	25%
D4910	Periodontal Maintenance	$156.00	$117.00	25%
D5110	Complete Denture - Maxillary	$1,364.00	$1,023.00	25%
D5120	Complete Denture - Mandibular	$1,364.00	$1,023.00	25%
D5213	Maxillary Partial - Cast Metal	$1,820.00	$1,365.00	25%
D5510	Repair Broken Complete Denture	$253.00	$189.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$441.00	$330.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$424.00	$318.00	25%

DENTURES
code	Description	retail Fee*	member pays	savings*
D6010	Surgical Placement Of Endosteal Implant	$2,222.00	$1,777.00	20%
D6057	Custom Fabricated Abutment	$1,049.00	$839.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,609.00	$1,287.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,599.00	$1,279.00	20%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,332.00	$999.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,205.00	$903.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,250.00	$937.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$45.00	12%
D0140	Limited Oral Evaluation, Problem Focused	$78.00	$70.00	10%
D0150	Comprehensive Oral Evaluation	$91.00	$81.00	11%
D0210	Intraoral - Complete Series	$135.00	$121.00	10%
D0220	Intraoral - Peripical First Image	$30.00	$27.00	10%
D0274	Bitewings - Four Images	$67.00	$60.00	10%
D0330	Panoramic Image	$115.00	$103.00	10%
D1110	Prophylaxis - Adult	$82.00	$73.00	11%
D1120	Prophylaxis - Child	$65.00	$58.00	11%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$42.00	$37.00	12%
D1351	Sealant - Per Tooth	$53.00	$47.00	11%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*

CROWNS
code	Description	retail Fee*	member pays	savings*

ROOT CANALS
code	Description	retail Fee*	member pays	savings*

PERIODONTICS
code	Description	retail Fee*	member pays	savings*

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$52.00	$26.00	50%
D0140	Limited Oral Evaluation	$75.00	$37.00	51%
D0150	Comprehensive Oral Evaluation	$79.00	$39.00	51%
D0210	X-Rays intraoral complete series	$134.00	$67.00	50%
D0220	X-Rays Intraoral periapical first film	$35.00	$17.00	51%
D0274	X-rays bitewings four films	$70.00	$35.00	50%
D0330	X-rays panoramic	$120.00	$60.00	50%
D1110	Prophylaxis Adult	$91.00	$45.00	51%
D1120	Prophylaxis Child	$68.00	$34.00	50%
D1208	Topical application of flouride-excluding varnish	$41.00	$20.00	51%
D1351	Sealant per tooth	$56.00	$28.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$158.00	$118.00	25%
D2150	Amalgam - Two Surfaces	$205.00	$153.00	25%
D2160	Amalgam - Three Surfures	$246.00	$184.00	25%
D2330	Resin one surface Anterior	$170.00	$127.00	25%
D2331	Resin two surface Anterior	$197.00	$147.00	25%
D2332	Resin three sufarce Anterior	$260.00	$195.00	25%
D2335	Resin Four Surface Anterior	$288.00	$216.00	25%
D2391	Resin based one surface composite posterior	$171.00	$128.00	25%
D2392	Resin based two surface conposite posterior	$221.00	$165.00	25%
D2393	Resin based three surface conposite posterior	$260.00	$195.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown porcelain Ceramic	$1,130.00	$847.00	25%
D2750	Crown porcelain fused to high noble	$1,130.00	$847.00	25%
D2751	Crown porcelain fused to predominantly base	$1,130.00	$847.00	25%
D2752	Crown porcelain fused to noble metal	$1,130.00	$847.00	25%
D2950	Core Buildup, including any pins	$310.00	$232.00	25%
D2952	Cast Post and core in add. To crown indirectly fabricated	$432.00	$324.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Anterior final Restoration RCT	$755.00	$566.00	25%
D3320	Bicuspid Final Restoration RCT	$870.00	$652.00	25%
D3330	Molar Final Restoration RCT	$1,030.00	$772.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Periodontal scaling and root planning	$330.00	$247.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$264.00	$198.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$151.00	$113.00	25%
D4910	Periodontal Maintenancce Procedure	$170.00	$127.00	25%
D5213	Maxillary Partial-Cast Metal	$1,906.00	$1,429.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,500.00	$1,200.00	20%
D6057	Custom Fabricated Abutment	$932.00	$745.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,590.00	$1,272.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Upper	$1,380.00	$1,035.00	25%
D5120	Complete Lower	$1,380.00	$1,035.00	25%
D5510	Repair broken complete denture	$315.00	$236.00	25%
D5730	Reline Complete Upper Denture	$395.00	$296.00	25%
D5740	Reline Upper Partial Denture	$395.00	$296.00	25%
D5750	Reline Complete Upper denture	$481.00	$360.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Crown Procelain fused to high noble metal	$1,130.00	$847.00	25%
D6752	Crown procelain fused to noble metal	$1,130.00	$847.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extration erupted tooth or exposed root (elevation/forcep removal)	$164.00	$123.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$50.00	$25.00	50%
D0140	Limited Oral Evaluation	$75.00	$37.00	51%
D0150	Comprehensive Oral Evaluation	$90.00	$45.00	50%
D0210	X-Rays intraoral complete series	$130.00	$65.00	50%
D0220	X-Rays Intraoral periapical first film	$30.00	$15.00	50%
D0274	X-rays bitewings four films	$65.00	$32.00	51%
D0330	X-rays panoramic	$110.00	$55.00	50%
D1110	Prophylaxis Adult	$90.00	$45.00	50%
D1120	Prophylaxis Child	$66.00	$33.00	50%
D1208	Topical application of flouride-excluding varnish	$45.00	$22.00	51%
D1351	Sealant per tooth	$55.00	$27.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2330	Resin one surface Anterior	$160.00	$120.00	25%
D2331	Resin two surface Anterior	$200.00	$150.00	25%
D2332	Resin three sufarce Anterior	$245.00	$183.00	25%
D2335	Resin Four Surface Anterior	$310.00	$232.00	25%
D2391	Resin based one surface composite posterior	$175.00	$131.00	25%
D2392	Resin based two surface conposite posterior	$230.00	$172.00	25%
D2393	Resin based three surface conposite posterior	$285.00	$213.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown porcelain Ceramic	$1,230.00	$922.00	25%
D2750	Crown porcelain fused to high noble	$1,100.00	$825.00	25%
D2950	Core Buildup, including any pins	$270.00	$202.00	25%
D2952	Cast Post and core in add. To crown indirectly fabricated	$400.00	$300.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Anterior final Restoration RCT	$740.00	$555.00	25%
D3320	Bicuspid Final Restoration RCT	$845.00	$633.00	25%
D3330	Molar Final Restoration RCT	$1,010.00	$757.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Periodontal scaling and root planning	$195.00	$146.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$85.00	$63.00	26%
D4910	Periodontal Maintenancce Procedure	$135.00	$101.00	25%
D5213	Maxillary Partial-Cast Metal	$1,680.00	$1,260.00	25%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Upper	$1,695.00	$1,271.00	25%
D5120	Complete Lower	$1,695.00	$1,271.00	25%
D5510	Repair broken complete denture	$210.00	$157.00	25%
D5730	Reline Complete Upper Denture	$400.00	$300.00	25%
D5740	Reline Upper Partial Denture	$400.00	$300.00	25%
D5750	Reline Complete Upper denture	$475.00	$356.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Crown Procelain fused to high noble metal	$1,115.00	$836.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extration erupted tooth or exposed root (elevation/forcep removal)	$175.00	$131.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$55.00	$27.00	51%
D0140	Limited Oral Evaluation	$72.00	$36.00	50%
D0150	Comprehensive Oral Evaluation	$130.00	$65.00	50%
D0210	X-Rays intraoral complete series	$135.00	$67.00	50%
D0220	X-Rays Intraoral periapical first film	$30.00	$15.00	50%
D0274	X-rays bitewings four films	$65.00	$32.00	51%
D0330	X-rays panoramic	$130.00	$65.00	50%
D1110	Prophylaxis Adult	$85.00	$42.00	51%
D1120	Prophylaxis Child	$63.00	$31.00	51%
D1208	Topical application of flouride-excluding varnish	$41.00	$20.00	51%
D1351	Sealant per tooth	$51.00	$25.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$153.00	$114.00	25%
D2150	Amalgam - Two Surfaces	$198.00	$148.00	25%
D2160	Amalgam - Three Surfures	$241.00	$180.00	25%
D2330	Resin one surface Anterior	$152.00	$114.00	25%
D2331	Resin two surface Anterior	$189.00	$141.00	25%
D2332	Resin three sufarce Anterior	$260.00	$195.00	25%
D2335	Resin Four Surface Anterior	$288.00	$216.00	25%
D2391	Resin based one surface composite posterior	$165.00	$123.00	25%
D2392	Resin based two surface conposite posterior	$215.00	$161.00	25%
D2393	Resin based three surface conposite posterior	$264.00	$198.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown porcelain Ceramic	$1,050.00	$787.00	25%
D2750	Crown porcelain fused to high noble	$1,007.00	$755.00	25%
D2751	Crown porcelain fused to predominantly base	$1,050.00	$787.00	25%
D2752	Crown porcelain fused to noble metal	$1,050.00	$787.00	25%
D2950	Core Buildup, including any pins	$270.00	$202.00	25%
D2952	Cast Post and core in add. To crown indirectly fabricated	$353.00	$264.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Anterior final Restoration RCT	$750.00	$562.00	25%
D3320	Bicuspid Final Restoration RCT	$840.00	$630.00	25%
D3330	Molar Final Restoration RCT	$999.00	$749.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Periodontal scaling and root planning	$259.00	$194.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$195.00	$146.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$151.00	$113.00	25%
D4910	Periodontal Maintenancce Procedure	$179.00	$134.00	25%
D5213	Maxillary Partial-Cast Metal	$1,595.00	$1,196.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,500.00	$1,200.00	20%
D6057	Custom Fabricated Abutment	$1,050.00	$840.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,200.00	$960.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Upper	$1,485.00	$1,113.00	25%
D5120	Complete Lower	$1,485.00	$1,113.00	25%
D5510	Repair broken complete denture	$216.00	$162.00	25%
D5730	Reline Complete Upper Denture	$338.00	$253.00	25%
D5740	Reline Upper Partial Denture	$332.00	$249.00	25%
D5750	Reline Complete Upper denture	$484.00	$363.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Crown Procelain fused to high noble metal	$1,007.00	$755.00	25%
D6751	Crown procelain fused predominantly base metal	$1,050.00	$787.00	25%
D6752	Crown procelain fused to noble metal	$1,050.00	$787.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extration erupted tooth or exposed root (elevation/forcep removal)	$159.00	$119.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$52.00	$26.00	50%
D0140	Limited Oral Evaluation, Problem Focused	$81.00	$40.00	51%
D0150	Comprehensive Oral Evaluation	$88.00	$44.00	50%
D0210	Intraoral - Complete Series	$137.00	$68.00	50%
D0220	Intraoral - Peripical First Image	$30.00	$15.00	50%
D0274	Bitewings - Four Images	$65.00	$32.00	51%
D0330	Panoramic Image	$118.00	$59.00	50%
D1110	Prophylaxis - Adult	$104.00	$52.00	50%
D1120	Prophylaxis - Child	$70.00	$35.00	50%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$32.00	$16.00	50%
D1351	Sealant - Per Tooth	$48.00	$24.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$139.00	$104.00	25%
D2150	Amalgam - Two Surfaces	$180.00	$135.00	25%
D2160	Amalgam - Three Surfures	$216.00	$162.00	25%
D2330	Composite - One Surface, Anterior	$173.00	$129.00	25%
D2331	Composite - Two Surfaces, Anterior	$209.00	$156.00	25%
D2332	Composite - Three Surfaces, Anterior	$246.00	$184.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$312.00	$234.00	25%
D2391	Composite - One Surface, Posterior	$184.00	$138.00	25%
D2392	Composite - Two Surfaces, Posterior	$236.00	$177.00	25%
D2393	Composite - Three Surfaces, Posterior	$288.00	$216.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,236.00	$927.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,339.00	$1,004.00	25%
D2751	Crown - Porcelain/Base Metal	$1,236.00	$927.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,236.00	$927.00	25%
D2950	Core Buildup, Including Any Pins When Required	$278.00	$208.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$819.00	$614.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$949.00	$711.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,159.00	$869.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$268.00	$201.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$193.00	$144.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$43.00	$32.00	26%
D4910	Periodontal Maintenance	$149.00	$111.00	26%
D5213	Maxillary Partial - Cast Metal	$1,854.00	$1,390.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,957.00	$1,565.00	20%
D6057	Custom Fabricated Abutment	$901.00	$720.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,442.00	$1,153.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,442.00	$1,153.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,853.00	$1,389.00	25%
D5120	Complete Denture - Mandibular	$1,803.00	$1,352.00	25%
D5510	Repair Broken Complete Denture	$160.00	$120.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$268.00	$201.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$304.00	$228.00	25%
D5750	Reline Denture - Maxillary (Lab)	$438.00	$328.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,236.00	$927.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$179.00	$134.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$45.00	12%
D0140	Limited Oral Evaluation, Problem Focused	$100.00	$90.00	10%
D0150	Comprehensive Oral Evaluation	$91.00	$81.00	11%
D0210	Intraoral - Complete Series	$135.00	$121.00	10%
D0220	Intraoral - Peripical First Image	$23.00	$20.00	13%
D0274	Bitewings - Four Images	$67.00	$60.00	10%
D0330	Panoramic Image	$115.00	$103.00	10%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$114.00	$102.00	11%
D2150	Amalgam - Two Surfaces	$149.00	$134.00	10%
D2160	Amalgam - Three Surfures	$172.00	$154.00	10%
D2330	Composite - One Surface, Anterior	$184.00	$165.00	10%
D2331	Composite - Two Surfaces, Anterior	$207.00	$186.00	10%
D2332	Composite - Three Surfaces, Anterior	$207.00	$186.00	10%
D2391	Composite - One Surface, Posterior	$184.00	$165.00	10%
D2392	Composite - Two Surfaces, Posterior	$207.00	$186.00	10%
D2393	Composite - Three Surfaces, Posterior	$207.00	$186.00	10%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2950	Core Buildup, Including Any Pins When Required	$207.00	$186.00	10%
D2952	Post And Core, Indirectly Fabricated	$349.00	$314.00	10%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$750.00	$675.00	10%
D3320	Endodontic Therapy, Bicuspid Tooth	$855.00	$769.00	10%
D3330	Endodontic Therapy, Molar Tooth	$1,060.00	$954.00	10%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$263.00	$236.00	10%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$191.00	$171.00	10%
D4910	Periodontal Maintenance	$142.00	$127.00	11%
D6010	Surgical Placement Of Endosteal Implant	$2,010.00	$1,809.00	10%

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$190.00	$171.00	10%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$45.00	12%
D0140	Limited Oral Evaluation, Problem Focused	$78.00	$70.00	10%
D0150	Comprehensive Oral Evaluation	$91.00	$81.00	11%
D0210	Intraoral - Complete Series	$135.00	$121.00	10%
D0220	Intraoral - Peripical First Image	$34.00	$30.00	12%
D0274	Bitewings - Four Images	$67.00	$60.00	10%
D0330	Panoramic Image	$115.00	$103.00	10%
D1110	Prophylaxis - Adult	$82.00	$73.00	11%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$138.00	$124.00	10%
D2150	Amalgam - Two Surfaces	$173.00	$155.00	10%
D2160	Amalgam - Three Surfures	$211.00	$189.00	10%
D2330	Composite - One Surface, Anterior	$158.00	$142.00	10%
D2331	Composite - Two Surfaces, Anterior	$196.00	$176.00	10%
D2332	Composite - Three Surfaces, Anterior	$243.00	$218.00	10%
D2391	Composite - One Surface, Posterior	$175.00	$157.00	10%
D2392	Composite - Two Surfaces, Posterior	$227.00	$204.00	10%
D2393	Composite - Three Surfaces, Posterior	$280.00	$252.00	10%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2751	Crown - Porcelain/Base Metal	$1,050.00	$945.00	10%
D2950	Core Buildup, Including Any Pins When Required	$267.00	$240.00	10%
D2952	Post And Core, Indirectly Fabricated	$409.00	$368.00	10%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$1,005.00	$904.00	10%
D3320	Endodontic Therapy, Bicuspid Tooth	$1,097.00	$987.00	10%
D3330	Endodontic Therapy, Molar Tooth	$1,195.00	$1,075.00	10%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$264.00	$237.00	10%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$191.00	$171.00	10%
D4910	Periodontal Maintenance	$142.00	$127.00	11%
D6010	Surgical Placement Of Endosteal Implant	$2,010.00	$1,809.00	10%

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$182.00	$163.00	10%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$45.00	12%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$69.00	10%
D0150	Comprehensive Oral Evaluation	$91.00	$81.00	11%
D0210	Intraoral - Complete Series	$135.00	$121.00	10%
D0220	Intraoral - Peripical First Image	$23.00	$20.00	13%
D0274	Bitewings - Four Images	$67.00	$60.00	10%
D0330	Panoramic Image	$115.00	$103.00	10%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$114.00	$102.00	11%
D2150	Amalgam - Two Surfaces	$149.00	$134.00	10%
D2160	Amalgam - Three Surfures	$172.00	$154.00	10%
D2330	Composite - One Surface, Anterior	$184.00	$165.00	10%
D2331	Composite - Two Surfaces, Anterior	$207.00	$186.00	10%
D2332	Composite - Three Surfaces, Anterior	$207.00	$186.00	10%
D2391	Composite - One Surface, Posterior	$184.00	$165.00	10%
D2392	Composite - Two Surfaces, Posterior	$207.00	$186.00	10%
D2393	Composite - Three Surfaces, Posterior	$207.00	$186.00	10%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2950	Core Buildup, Including Any Pins When Required	$207.00	$186.00	10%
D2952	Post And Core, Indirectly Fabricated	$349.00	$314.00	10%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$982.00	$883.00	10%
D3320	Endodontic Therapy, Bicuspid Tooth	$1,097.00	$987.00	10%
D3330	Endodontic Therapy, Molar Tooth	$1,212.00	$1,090.00	10%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$263.00	$236.00	10%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$191.00	$171.00	10%
D4910	Periodontal Maintenance	$142.00	$127.00	11%
D6010	Surgical Placement Of Endosteal Implant	$2,010.00	$1,809.00	10%

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$160.00	$144.00	10%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*

CROWNS
code	Description	retail Fee*	member pays	savings*

ROOT CANALS
code	Description	retail Fee*	member pays	savings*

PERIODONTICS
code	Description	retail Fee*	member pays	savings*

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$25.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$98.00	$49.00	50%
D0210	Intraoral - Complete Series	$133.00	$66.00	50%
D0220	Intraoral - Peripical First Image	$35.00	$17.00	51%
D0274	Bitewings - Four Images	$74.00	$37.00	50%
D0330	Panoramic Image	$127.00	$63.00	50%
D1110	Prophylaxis - Adult	$103.00	$51.00	50%
D1120	Prophylaxis - Child	$77.00	$38.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$43.00	$21.00	51%
D1351	Sealant - Per Tooth	$63.00	$31.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$165.00	$123.00	25%
D2150	Amalgam - Two Surfaces	$206.00	$154.00	25%
D2160	Amalgam - Three Surfures	$251.00	$188.00	25%
D2330	Composite - One Surface, Anterior	$166.00	$124.00	25%
D2331	Composite - Two Surfaces, Anterior	$230.00	$172.00	25%
D2332	Composite - Three Surfaces, Anterior	$282.00	$211.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$352.00	$264.00	25%
D2391	Composite - One Surface, Posterior	$204.00	$153.00	25%
D2392	Composite - Two Surfaces, Posterior	$261.00	$195.00	25%
D2393	Composite - Three Surfaces, Posterior	$322.00	$241.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,269.00	$951.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,271.00	$953.00	25%
D2751	Crown - Porcelain/Base Metal	$1,059.00	$794.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,221.00	$915.00	25%
D2950	Core Buildup, Including Any Pins When Required	$302.00	$226.00	25%
D2952	Post And Core, Indirectly Fabricated	$465.00	$348.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$764.00	$573.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$952.00	$714.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,172.00	$879.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$287.00	$215.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$211.00	$158.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$161.00	$120.00	25%
D4910	Periodontal Maintenance	$153.00	$114.00	25%
D5213	Maxillary Partial - Cast Metal	$1,820.00	$1,365.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,171.00	$1,736.00	20%
D6057	Custom Fabricated Abutment	$1,026.00	$820.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,572.00	$1,257.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,562.00	$1,249.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,364.00	$1,023.00	25%
D5120	Complete Denture - Mandibular	$1,364.00	$1,023.00	25%
D5510	Repair Broken Complete Denture	$247.00	$185.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$431.00	$323.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$415.00	$311.00	25%
D5750	Reline Denture - Maxillary (Lab)	$532.00	$399.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,303.00	$977.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,178.00	$883.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,221.00	$915.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$201.00	$150.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$44.00	$22.00	50%
D0140	Limited Oral Evaluation, Problem Focused	$62.00	$31.00	50%
D0150	Comprehensive Oral Evaluation	$69.00	$34.00	51%
D0210	Intraoral - Complete Series	$119.00	$59.00	50%
D0220	Intraoral - Peripical First Image	$25.00	$12.00	52%
D0274	Bitewings - Four Images	$56.00	$28.00	50%
D0330	Panoramic Image	$100.00	$50.00	50%
D1110	Prophylaxis - Adult	$82.00	$41.00	50%
D1120	Prophylaxis - Child	$59.00	$29.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$32.00	$16.00	50%
D1351	Sealant - Per Tooth	$44.00	$22.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$89.00	$66.00	26%
D2150	Amalgam - Two Surfaces	$138.00	$103.00	25%
D2160	Amalgam - Three Surfures	$156.00	$117.00	25%
D2330	Composite - One Surface, Anterior	$135.00	$101.00	25%
D2331	Composite - Two Surfaces, Anterior	$161.00	$120.00	25%
D2332	Composite - Three Surfaces, Anterior	$191.00	$143.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$263.00	$197.00	25%
D2391	Composite - One Surface, Posterior	$148.00	$111.00	25%
D2392	Composite - Two Surfaces, Posterior	$183.00	$137.00	25%
D2393	Composite - Three Surfaces, Posterior	$196.00	$147.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$935.00	$701.00	25%
D2750	Crown - Porcelain/High Noble Metal	$935.00	$701.00	25%
D2751	Crown - Porcelain/Base Metal	$935.00	$701.00	25%
D2752	Crown - Porcelain/Noble Metal	$935.00	$701.00	25%
D2950	Core Buildup, Including Any Pins When Required	$232.00	$174.00	25%
D2952	Post And Core, Indirectly Fabricated	$299.00	$224.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$525.00	$393.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$688.00	$516.00	25%
D3330	Endodontic Therapy, Molar Tooth	$840.00	$630.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$184.00	$138.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$100.00	$75.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$74.00	$55.00	26%
D4910	Periodontal Maintenance	$79.00	$59.00	25%
D5213	Maxillary Partial - Cast Metal	$924.00	$693.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,575.00	$1,260.00	20%
D6057	Custom Fabricated Abutment	$1,575.00	$1,260.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,575.00	$1,260.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,575.00	$1,260.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$893.00	$669.00	25%
D5120	Complete Denture - Mandibular	$893.00	$669.00	25%
D5510	Repair Broken Complete Denture	$138.00	$103.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$184.00	$138.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$158.00	$118.00	25%
D5750	Reline Denture - Maxillary (Lab)	$270.00	$202.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$788.00	$591.00	25%
D6751	Abutment - Porcelain/Base Metal	$935.00	$701.00	25%
D6752	Abutment - Porcelain/Noble Metal	$935.00	$701.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$143.00	$107.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$25.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$90.00	$45.00	50%
D0210	Intraoral - Complete Series	$133.00	$66.00	50%
D0220	Intraoral - Peripical First Image	$36.00	$18.00	50%
D0274	Bitewings - Four Images	$66.00	$33.00	50%
D0330	Panoramic Image	$112.00	$56.00	50%
D1110	Prophylaxis - Adult	$95.00	$47.00	51%
D1120	Prophylaxis - Child	$68.00	$34.00	50%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$44.00	$22.00	50%
D1351	Sealant - Per Tooth	$56.00	$28.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$145.00	$108.00	26%
D2150	Amalgam - Two Surfaces	$182.00	$136.00	25%
D2160	Amalgam - Three Surfures	$222.00	$166.00	25%
D2330	Composite - One Surface, Anterior	$166.00	$124.00	25%
D2331	Composite - Two Surfaces, Anterior	$206.00	$154.00	25%
D2332	Composite - Three Surfaces, Anterior	$255.00	$191.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$321.00	$240.00	25%
D2391	Composite - One Surface, Posterior	$184.00	$138.00	25%
D2392	Composite - Two Surfaces, Posterior	$238.00	$178.00	25%
D2393	Composite - Three Surfaces, Posterior	$294.00	$220.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,171.00	$878.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,149.00	$861.00	25%
D2751	Crown - Porcelain/Base Metal	$1,059.00	$794.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,084.00	$813.00	25%
D2950	Core Buildup, Including Any Pins When Required	$280.00	$210.00	25%
D2952	Post And Core, Indirectly Fabricated	$429.00	$321.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$764.00	$573.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$874.00	$655.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,047.00	$785.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$264.00	$198.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$191.00	$143.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$147.00	$110.00	25%
D4910	Periodontal Maintenance	$141.00	$105.00	26%
D5213	Maxillary Partial - Cast Metal	$1,820.00	$1,365.00	25%
D6010	Surgical Placement Of Endosteal Implant	$1,835.00	$1,468.00	20%
D6057	Custom Fabricated Abutment	$958.00	$766.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,477.00	$1,181.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,386.00	$1,108.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,364.00	$1,023.00	25%
D5120	Complete Denture - Mandibular	$1,364.00	$1,023.00	25%
D5510	Repair Broken Complete Denture	$216.00	$162.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$382.00	$286.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$373.00	$279.00	25%
D5750	Reline Denture - Maxillary (Lab)	$484.00	$363.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,151.00	$863.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,083.00	$812.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,092.00	$819.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$181.00	$135.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$51.00	$25.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$77.00	$38.00	51%
D0150	Comprehensive Oral Evaluation	$99.00	$49.00	51%
D0210	Intraoral - Complete Series	$149.00	$74.00	50%
D0220	Intraoral - Peripical First Image	$39.00	$19.00	51%
D0274	Bitewings - Four Images	$83.00	$41.00	51%
D0330	Panoramic Image	$144.00	$72.00	50%
D1110	Prophylaxis - Adult	$103.00	$51.00	50%
D1120	Prophylaxis - Child	$77.00	$38.00	51%
D1208	Topical Fluoride Adult/Child - Excluding Varnish	$44.00	$22.00	50%
D1351	Sealant - Per Tooth	$62.00	$31.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$187.00	$140.00	25%
D2150	Amalgam - Two Surfaces	$233.00	$174.00	25%
D2160	Amalgam - Three Surfures	$285.00	$213.00	25%
D2330	Composite - One Surface, Anterior	$187.00	$140.00	25%
D2331	Composite - Two Surfaces, Anterior	$260.00	$195.00	25%
D2332	Composite - Three Surfaces, Anterior	$320.00	$240.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$398.00	$298.00	25%
D2391	Composite - One Surface, Posterior	$231.00	$173.00	25%
D2392	Composite - Two Surfaces, Posterior	$296.00	$222.00	25%
D2393	Composite - Three Surfaces, Posterior	$365.00	$273.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,439.00	$1,079.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,440.00	$1,080.00	25%
D2751	Crown - Porcelain/Base Metal	$1,172.00	$879.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,383.00	$1,037.00	25%
D2950	Core Buildup, Including Any Pins When Required	$343.00	$257.00	25%
D2952	Post And Core, Indirectly Fabricated	$527.00	$395.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$847.00	$635.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$1,079.00	$809.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,328.00	$996.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$326.00	$244.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$239.00	$179.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$183.00	$137.00	25%
D4910	Periodontal Maintenance	$173.00	$129.00	25%
D5213	Maxillary Partial - Cast Metal	$1,820.00	$1,365.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,461.00	$1,968.00	20%
D6057	Custom Fabricated Abutment	$1,162.00	$929.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,782.00	$1,425.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,770.00	$1,416.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,364.00	$1,023.00	25%
D5120	Complete Denture - Mandibular	$1,364.00	$1,023.00	25%
D5510	Repair Broken Complete Denture	$280.00	$210.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$488.00	$366.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$470.00	$352.00	25%
D5750	Reline Denture - Maxillary (Lab)	$603.00	$452.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,476.00	$1,107.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,335.00	$1,001.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,383.00	$1,037.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$198.00	$148.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$46.00	$23.00	50%
D0140	Limited Oral Evaluation, Problem Focused	$75.00	$37.00	51%
D0145	Oral Eval Pt Under 3 Yrs, Counsel Primary	$51.00	$25.00	51%
D0150	Comprehensive Oral Evaluation	$72.00	$36.00	50%
D0170	Re-Evaluation, Problem Focused	$173.00	$86.00	50%
D0240	Intraoral - Occlusal Image	$44.00	$22.00	50%
D0274	Bitewings - Four Images	$64.00	$32.00	50%
D0330	Panoramic Image	$117.00	$58.00	50%
D0460	Pulp Vitality Tests	$39.00	$19.00	51%
D1110	Prophylaxis - Adult	$86.00	$43.00	50%
D1120	Prophylaxis - Child	$75.00	$37.00	51%
D1206	Topical Fluoride Varnish	$48.00	$24.00	50%
D1351	Sealant - Per Tooth	$72.00	$36.00	50%
D1525	Space Maintainer - Removable Bilateral	$253.00	$126.00	50%
D2394	Composite - Four/More Surfaces, Posterior	$281.00	$210.00	25%
D2510	Inlay Metallic - One Surface	$622.00	$466.00	25%
D2530	Inlay Metallic - Three/More Surfaces	$975.00	$731.00	25%
D2940	Protective Restoration	$123.00	$92.00	25%
D2954	Prefabricated Post And Core	$440.00	$330.00	25%
D2960	Labial Veneer (Resin Laminate) - Chair	$565.00	$423.00	25%
D8040	Limited Adult Dentition	$2,499.00	$1,874.00	25%
D8090	Comprehensive Adult Dentition	$4,074.00	$3,055.00	25%
D8680	Ortho Retention	$238.00	$178.00	25%
D8692	Replace Lost/Broken Retainer	$238.00	$178.00	25%
D9215	Local Anesthesia With Surgical Procedures	$33.00	$24.00	27%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2331	Composite - Two Surfaces, Anterior	$204.00	$153.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$278.00	$208.00	25%
D2391	Composite - One Surface, Posterior	$171.00	$128.00	25%
D2392	Composite - Two Surfaces, Posterior	$202.00	$151.00	25%
D2393	Composite - Three Surfaces, Posterior	$259.00	$194.00	25%
D2542	Onlay Metallic - Two Surfaces	$810.00	$607.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2710	Crown - Composite (Indirect)	$220.00	$165.00	25%
D2751	Crown - Porcelain/Base Metal	$1,018.00	$763.00	25%
D2790	Crown - Full Cast High Noble Metal	$1,091.00	$818.00	25%
D2791	Crown - Full Cast Base Metal	$1,018.00	$763.00	25%
D2950	Core Buildup, Including Any Pins When Required	$225.00	$168.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$792.00	$594.00	25%
D3331	Treatment Of Root Canal Obstruction	$798.00	$598.00	25%
D4210	Gingivectomy - 4/More Per Quad	$414.00	$310.00	25%
D4211	Gingivectomy - 1-3 Teeth Per Quad	$193.00	$144.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D5213	Maxillary Partial - Cast Metal	$1,525.00	$1,143.00	25%
D5411	Adjustment Denture - Mandibular	$76.00	$57.00	25%
D5422	Adjustment Partial - Mandibular	$76.00	$57.00	25%
D5610	Repair Resin Partial Denture Base	$165.00	$123.00	25%
D5761	Reline Partial - Mandibular (Lab)	$550.00	$412.00	25%
D5810	Interim Denture - Maxillary	$990.00	$742.00	25%
D6190	Radiographic/Surgical Implant Index, By Report	$281.00	$224.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,345.00	$1,008.00	25%
D5140	Immediate Denture - Mandibular	$1,492.00	$1,119.00	25%
D5510	Repair Broken Complete Denture	$169.00	$126.00	25%
D5520	Replace Missing Or Broken Teeth	$169.00	$126.00	25%
D6791	Abutment - Full Cast Base Metal	$1,018.00	$763.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6721	Abutment - Resin/Base Metal	$1,018.00	$763.00	25%
D6782	Abutment - 3/4 Cast Noble Metal	$1,018.00	$763.00	25%
D6783	Abutment - 3/4 Porcelain/Ceramic	$1,018.00	$763.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$165.00	$123.00	25%
D7260	Oroantral Fistula Closure	$330.00	$247.00	25%
D7951	Sinus Augmentation	$815.00	$611.00	25%
D7953	Bone Replacment Graft For Ridge - Per Site	$354.00	$265.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0120	Periodic Oral Evaluation	$53.00	$26.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$79.00	$39.00	51%
D0150	Comprehensive Oral Evaluation	$93.00	$46.00	51%
D0210	Intraoral - Complete Series	$139.00	$69.00	50%
D0220	Intraoral - Peripical First Image	$32.00	$16.00	50%
D0274	Bitewings - Four Images	$69.00	$34.00	51%
D0330	Panoramic Image	$119.00	$59.00	50%
D1110	Prophylaxis - Adult	$95.00	$47.00	51%
D1120	Prophylaxis - Child	$72.00	$36.00	50%
D1351	Sealant - Per Tooth	$57.00	$28.00	51%
D0120	Periodic Oral Evaluation	$53.00	$26.00	51%
D0140	Limited Oral Evaluation, Problem Focused	$79.00	$39.00	51%
D0150	Comprehensive Oral Evaluation	$93.00	$46.00	51%
D0210	Intraoral - Complete Series	$139.00	$69.00	50%
D0220	Intraoral - Peripical First Image	$32.00	$16.00	50%
D0274	Bitewings - Four Images	$69.00	$34.00	51%
D0330	Panoramic Image	$119.00	$59.00	50%
D1110	Prophylaxis - Adult	$95.00	$47.00	51%
D1120	Prophylaxis - Child	$72.00	$36.00	50%
D1351	Sealant - Per Tooth	$57.00	$28.00	51%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$153.00	$114.00	25%
D2150	Amalgam - Two Surfaces	$235.00	$176.00	25%
D2160	Amalgam - Three Surfures	$235.00	$176.00	25%
D2330	Composite - One Surface, Anterior	$177.00	$132.00	25%
D2331	Composite - Two Surfaces, Anterior	$215.00	$161.00	25%
D2332	Composite - Three Surfaces, Anterior	$263.00	$197.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$330.00	$247.00	25%
D2391	Composite - One Surface, Posterior	$191.00	$143.00	25%
D2392	Composite - Two Surfaces, Posterior	$244.00	$183.00	25%
D2393	Composite - Three Surfaces, Posterior	$302.00	$226.00	25%
D2140	Amalgam - One Surface	$153.00	$114.00	25%
D2150	Amalgam - Two Surfaces	$235.00	$176.00	25%
D2160	Amalgam - Three Surfures	$235.00	$176.00	25%
D2330	Composite - One Surface, Anterior	$177.00	$132.00	25%
D2331	Composite - Two Surfaces, Anterior	$215.00	$161.00	25%
D2332	Composite - Three Surfaces, Anterior	$263.00	$197.00	25%
D2335	Composite - Four/More Surfaces, Anterior	$330.00	$247.00	25%
D2391	Composite - One Surface, Posterior	$191.00	$143.00	25%
D2392	Composite - Two Surfaces, Posterior	$244.00	$183.00	25%
D2393	Composite - Three Surfaces, Posterior	$302.00	$226.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown - Porcelain/Ceramic	$1,197.00	$897.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,201.00	$900.00	25%
D2751	Crown - Porcelain/Base Metal	$1,112.00	$834.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,149.00	$861.00	25%
D2950	Core Buildup, Including Any Pins When Required	$285.00	$213.00	25%
D2952	Post And Core, Indirectly Fabricated	$441.00	$330.00	25%
D2740	Crown - Porcelain/Ceramic	$1,197.00	$897.00	25%
D2750	Crown - Porcelain/High Noble Metal	$1,201.00	$900.00	25%
D2751	Crown - Porcelain/Base Metal	$1,112.00	$834.00	25%
D2752	Crown - Porcelain/Noble Metal	$1,149.00	$861.00	25%
D2950	Core Buildup, Including Any Pins When Required	$285.00	$213.00	25%
D2952	Post And Core, Indirectly Fabricated	$441.00	$330.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Endodontic Therapy, Anterior Tooth	$788.00	$591.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$898.00	$673.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,094.00	$820.00	25%
D3310	Endodontic Therapy, Anterior Tooth	$788.00	$591.00	25%
D3320	Endodontic Therapy, Bicuspid Tooth	$898.00	$673.00	25%
D3330	Endodontic Therapy, Molar Tooth	$1,094.00	$820.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$268.00	$201.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$194.00	$145.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$144.00	$108.00	25%
D4910	Periodontal Maintenance	$143.00	$107.00	25%
D5213	Maxillary Partial - Cast Metal	$1,867.00	$1,400.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,030.00	$1,624.00	20%
D6057	Custom Fabricated Abutment	$956.00	$764.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,503.00	$1,202.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,450.00	$1,160.00	20%
D4341	Perio Scaling/Root Planing - 4/More Per Quad	$268.00	$201.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$194.00	$145.00	25%
D4381	Localized Delivery Of Antimicrobial Agents	$144.00	$108.00	25%
D4910	Periodontal Maintenance	$143.00	$107.00	25%
D5213	Maxillary Partial - Cast Metal	$1,867.00	$1,400.00	25%
D6010	Surgical Placement Of Endosteal Implant	$2,030.00	$1,624.00	20%
D6057	Custom Fabricated Abutment	$956.00	$764.00	20%
D6058	Abutment Supported Crown - Porcln/Ceramic	$1,503.00	$1,202.00	20%
D6060	Abutment Supported Crown - Porcln/Base Metal	$1,450.00	$1,160.00	20%

DENTURES
code	Description	retail Fee*	member pays	savings*
D5110	Complete Denture - Maxillary	$1,840.00	$1,380.00	25%
D5120	Complete Denture - Mandibular	$1,832.00	$1,374.00	25%
D5510	Repair Broken Complete Denture	$226.00	$169.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$394.00	$295.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$383.00	$287.00	25%
D5750	Reline Denture - Maxillary (Lab)	$491.00	$368.00	25%
D5110	Complete Denture - Maxillary	$1,840.00	$1,380.00	25%
D5120	Complete Denture - Mandibular	$1,832.00	$1,374.00	25%
D5510	Repair Broken Complete Denture	$226.00	$169.00	25%
D5730	Reline Denture - Maxillary (Chairside)	$394.00	$295.00	25%
D5740	Reline Partial - Maxillary (Chairside)	$383.00	$287.00	25%
D5750	Reline Denture - Maxillary (Lab)	$491.00	$368.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6750	Abutment - Porcelain/High Noble Metal	$1,206.00	$904.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,101.00	$825.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,138.00	$853.00	25%
D6750	Abutment - Porcelain/High Noble Metal	$1,206.00	$904.00	25%
D6751	Abutment - Porcelain/Base Metal	$1,101.00	$825.00	25%
D6752	Abutment - Porcelain/Noble Metal	$1,138.00	$853.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7140	Extraction, Erupted Tooth/Exposed Root	$186.00	$139.00	25%
D7140	Extraction, Erupted Tooth/Exposed Root	$186.00	$139.00	25%

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*

CROWNS
code	Description	retail Fee*	member pays	savings*

ROOT CANALS
code	Description	retail Fee*	member pays	savings*

PERIODONTICS
code	Description	retail Fee*	member pays	savings*

DENTURES
code	Description	retail Fee*	member pays	savings*

BRIDGES
code	Description	retail Fee*	member pays	savings*

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*

DIAGNOSTIC AND PREVENTIVE
code	Description	retail Fee*	member pays	savings*
D0274	X-rays bitewings four films	$68.00	$34.00	50%
D0220	X-Rays Intraoral periapical first film	$32.00	$16.00	50%
D0210	X-Rays intraoral complete series	$144.00	$72.00	50%
D0140	Limited Oral Evaluation	$81.00	$40.00	51%
D0120	Periodic Oral Evaluation	$48.00	$24.00	50%
D0330	X-rays panoramic	$149.00	$74.00	50%
D0150	Comprehensive Oral Evaluation	$81.00	$40.00	51%
D1110	Prophylaxis Adult	$92.00	$46.00	50%
D1120	Prophylaxis Child	$64.00	$32.00	50%
D1208	Topical application of flouride-excluding varnish	$26.00	$13.00	50%
D1351	Sealant per tooth	$58.00	$29.00	50%

RESTORATIVE - COMPOSITE FILLINGS (RESIN BASED)
code	Description	retail Fee*	member pays	savings*
D2140	Amalgam - One Surface	$168.00	$126.00	25%
D2150	Amalgam - Two Surfaces	$218.00	$163.00	25%
D2160	Amalgam - Three Surfures	$271.00	$203.00	25%
D2330	Resin one surface Anterior	$156.00	$117.00	25%
D2331	Resin two surface Anterior	$194.00	$145.00	25%
D2332	Resin three sufarce Anterior	$243.00	$182.00	25%
D2335	Resin Four Surface Anterior	$282.00	$211.00	25%
D2391	Resin based one surface composite posterior	$179.00	$134.00	25%
D2392	Resin based two surface conposite posterior	$228.00	$171.00	25%
D2393	Resin based three surface conposite posterior	$290.00	$217.00	25%

CROWNS
code	Description	retail Fee*	member pays	savings*
D2740	Crown porcelain Ceramic	$1,122.00	$841.00	25%
D2750	Crown porcelain fused to high noble	$1,184.00	$888.00	25%
D2751	Crown porcelain fused to predominantly base	$1,045.00	$783.00	25%
D2752	Crown porcelain fused to noble metal	$1,122.00	$841.00	25%
D2950	Core Buildup, including any pins	$281.00	$210.00	25%
D2952	Cast Post and core in add. To crown indirectly fabricated	$452.00	$339.00	25%

ROOT CANALS
code	Description	retail Fee*	member pays	savings*
D3310	Anterior final Restoration RCT	$795.00	$596.00	25%
D3320	Bicuspid Final Restoration RCT	$870.00	$652.00	25%
D3330	Molar Final Restoration RCT	$1,077.00	$807.00	25%

PERIODONTICS
code	Description	retail Fee*	member pays	savings*
D4341	Periodontal scaling and root planning	$295.00	$221.00	25%
D4342	Perio Scaling/Root Planing - 1-3 Teeth Per Quad	$193.00	$144.00	25%
D4355	Localized Delivery Of Antimicrobial Agents	$72.00	$54.00	25%
D4381	Periodontal Maintenancce Procedure	$92.00	$69.00	25%
D5212	Maxillary Partial-Cast Metal	$1,813.00	$1,359.00	25%
D5994	Surgical Placement Of Endosteal Implant	$1,917.00	$1,437.00	25%
D6056	Custom Fabricated Abutment	$726.00	$544.00	25%
D6057	Abutment Supported Crown - Porcln/Ceramic	$1,347.00	$1,010.00	25%
D6059	Abutment Supported Crown - Porcln/Base Metal	$1,373.00	$1,029.00	25%

DENTURES
code	Description	retail Fee*	member pays	savings*
D4921	Complete Upper	$1,697.00	$1,272.00	25%
D5110	Complete Lower	$1,697.00	$1,272.00	25%
D5422	Repair broken complete denture	$219.00	$164.00	25%
D5721	Reline Complete Upper Denture	$433.00	$324.00	25%
D5731	Reline Upper Partial Denture	$365.00	$273.00	25%
D5741	Reline Complete Upper denture	$520.00	$390.00	25%

BRIDGES
code	Description	retail Fee*	member pays	savings*
D6740	Crown Procelain fused to high noble metal	$1,122.00	$841.00	25%
D6750	Crown procelain fused predominantly base metal	$1,036.00	$777.00	25%
D6751	Crown procelain fused to noble metal	$1,083.00	$812.00	25%

EXTRACTIONS
code	Description	retail Fee*	member pays	savings*
D7111	Extration erupted tooth or exposed root (elevation/forcep removal)	$163.00	$122.00	25%

Fee Schedule - Georgia Fee Schedule - Georgia

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*Member savings is the amount members pay less their affiliated office's retail fees. The retail fee refers to the normal rate affiliated offices charge uninsured, self-pay patients for services rendered. Retail fees and member savings may vary by affiliated provider. 10% member savings in lieu of 20-50% savings if board certified specialist renders services.

Finance Options

Smile Care Savings Plan members may also apply for financing to help pay for procedures included in their dentist's recommended treatment plan. Please speak directly with your affiliated office to inquire about available financing options.

Optional Treatment Financing

Deferred and Fixed Interest Options

Low Monthly Payments

Quick & Easy Approval Process

Member Testimonials

Janice & Derian

"Since Medicare doesn't cover dental we were looking for an
affordable solution to save us money each time we visit the
dentist. Smile Care Savings Plan is perfect for seniors that
don't have dental. We love that Smile Care keeps it simple
with no waiting periods, maximums, or exclusions."

Zak & Mindy

"Our employer offered dental insurance was expensive and
lacked value. We needed a dental plan that is affordable,
easy-to-use with significant real dollar savings. For only
about $6.50 per month, Smile Care Savings Plan saves us
10-50% each and every time we visit the dentist."

Savings Summary