Savings Summary

Making quality dental care affordable for everyone is what we do.

Save up to 50% on all dental procedures by enrolling as a member today. Smile Care Savings Plan keeps it simple by featuring no waiting periods, exclusions or maximums and transparent member-only savings on all preventive, basic, major, cosmetic, orthodontic and specialty dental procedures.

Select your affiliated Smile Care office to view your member savings:

DIAGNOSTIC AND PREVENTIVE
code Description retail Fee* member pays savings*
D0120 Oral Evaluation $80.00 $40.00 50%
D0140 Limited Oral Evaluation, Problem Focused $89.00 $44.00 51%
D0150 Comprehensive Oral Evaluation $106.00 $53.00 50%
D0210 Intraoral - Complete Series $154.00 $77.00 50%
D0220 Intraoral - Peripical First Image $33.00 $16.00 52%
D0274 Bitewings - Four Images $76.00 $38.00 50%
D0330 Panoramic Image $135.00 $67.00 50%
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 $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%

Finance Options

Smile Care Savings Plan members may also apply for financing to help pay for procedures included in their treatment plan. Please speak directly with your affiliated Smile Care office to see what finance options are available for you.

Financing Options Available

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Deferred and Fixed Interest Options

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Low Monthly Payments

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Quick and Easy Approval Process

Testimonials

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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, and exclusions."

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Zak & Mindy

"Our employer offered dental insurance was expensive and
lacked value. We needed a dental plan that is affordable,
easy-to-use, and has significant real dollar savings. For only
about $6.50 per month, Smile Care Savings Plan saves us
20-50% each and every time we visit the dentist."