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These are the actual fees you will pay at the dentist office. These fees have already been discounted. You will save an average of 50% off the usual and customary fees on your general dentistry. If you need a specialist, ours offer a 25% discount from their usual and customary fees (unless otherwise noted in the provider listing). You may go to any participating dentist at any time.
| Dental Procedures | ADA Code | Plan Fees |
| Infection Control - per visit | $10 | |
| Diagnostic Dentistry | ||
| Initial Office Visit & Oral Exam | D0150 | $36 |
| Periodic Oral Exam | D0120 | $30 |
| Emergency Oral Exam | D9110 | $40 |
| X-Ray-Complete Series | D0210 | $48 |
| X-Ray Single | D0220 | $9 |
| X-Ray Intraoral-periapical -each additional film | D0230 | $9 |
| X-Ray-Bitewing (2 Films) | D0272 | $16 |
| X-Ray-Bitewing (4 Films) | D0274 | $28 |
| X-Ray-Vertical Bitewings - 7 to 8 Films | D0277 | $48 |
| X-Ray-Panoramic | D0330 | $52 |
| Preventative Dentistry | ||
| Teeth Cleaning (Adult-include scaling) | D1110 | $42 |
| Teeth Cleaning (Child-up to 12 yrs old) | D1120 | $35 |
| Teeth Cleaning - Over 1 yr since last | D4999 | $65 |
| Deep Scaling (Full Mouth) | D4345 | $115 |
| Stannous Fluoride Treatment | D1201, D1205 | 25% Discount |
| Topical Application of Fluoride | D1203, D1204 | $10 |
| Space Maintainer Fixed - Unilateral | D1510 | $160 |
| Space Maintainer Fixed - Bilateral | D1515 | $185 |
| Restorative Dentistry | ||
| Amalgam Filling (1 Surface) | D2140 | $58 |
| Amalgam Filling (2 Surface) | D2150 | $68 |
| Amalgam Filling (3 Surface) | D2160 | $83 |
| Composite Filling (1 Surface-Anterior) | D2330 | $73 |
| Composite Filling (2 Surface-Anterior) | D2331 | $93 |
| Composite Filling (3 Surface-Anterior) | D2332 | $108 |
| Composite Filling Involving Incisal Angle | D2335 | $160 |
| Composite Filling (1 Surface-Posterior) | D2391 | $88 |
| Composite Filling (2 Surface-Posterior) | D2392 | $102 |
| Composite Filling (3 Surface-Posterior) | D2393 | $130 |
| Crowns and Bridges | ||
| Crown - Porcelain | D2740 | $662 |
| Crown - Porcelain fused to High Noble | D2750 | $662 |
| Crown - Porcelain fused to Metal | D2751 | $550 |
| Crown - Porcelain fused to Noble Metal | D2752 | $550 |
| Crown - Full Cast High Noble Metal | D2790 | $662 |
| Crown - Full Cast Predom. Base Metal | D2791 | $530 |
| Crown - Full Cast Noble Metal | D2792 | $550 |
| Crown - 3/4 Cast Metallic | D2810 | $525 |
| Crown - Stainless - Child | D2930 | $160 |
| Crown - Stainless - Permanent Tooth | D2931 | $175 |
| Core Buildup with pins | D2950 | $152 |
| Pin Retention (per tooth) | D2951 | $28 |
| Cast Post and Core in addition to Crown | D2952 | $193 |
| Post & Core Buildup (prefabricated post) | D2954 | $170 |
| Fixed Bridge (per unit) porcelain HNM | D6750 | $655 |
| Fixed Bridge (per unit) porcelain PBM | D6751 | $595 |
| Endodontics (performed by general dentist) | ||
| Pulp Cap Direct | D3110 | $38 |
| Vital Pulpotomy | D3220 | $78 |
| Root Canal Therapy 1Canal | D3310 | $335 |
| Root Canal Therapy 2 Canals | D3320 | $425 |
| Root Canal Therapy 3 Canals | D3330 | $515 |
| Root Canal Therapy 4 Canals | D3340 | 25% Discount |
| Routine Oral Surgery (performed by general dentist) | ||
| Simple Extraction | D7110 | $70 |
| Root Removal - Exposed | D7130 | $90 |
| Surgical Extraction | D7210 | 25% Discount |
| Soft Tissue Impaction | D7220 | 25% Discount |
| Bony Impaction | D7230, D7240 | 25% Discount |
| Prosthodontics (performed by general dentist) | ||
| Full Denture (per unit-maxillary) | D5110 | $795 |
| Full Denture (per unit-mandibular) | D5120 | $795 |
| Partial Denture (chrome Lingual or Palatal Bar, 2 Clasps, Acrylic Base) | D5211, D5212 | $545 |
| All Other Partial Dentures | D6999 | 25% Discount |
| Reline (chair side) | D5730, D5731 | $175 |
| Reline-upper or lower partial (chair side) | D5740, D5741 | $175 |
| Reline (laboratory) | D5750, D5751 | $210 |
| Prosthodontic Services Not Listed | D5899 | 25% Discount |
| Routine Periodontics (performed by general dentist) | ||
| Gingivectomy or Gingivoplasty-per Quad. | D4210 | $305 |
| Gingivectomy or Gingivoplasty-per Tooth | D4211 | $150 |
| Osseous (bone) surgery per Quadrant | D4260 | $490 |
| Periodontal Scaling & Root Planning - per Quadrant | D4341 | $115 |
| Post Operative Exam and Prophylaxis | D4910 | $60 |
| Other Services | ||
| Cosmetic Bonding/Veneers | 25% Discount | |
| Sealant - per tooth | D1351 | 25% Discount |
| Office Visit No Treatment | D9430 | $10 |
| Missed Appointment w/o 24 Hr Notice | $30 | |
| Emergency Treatment After Regular Office Hours | Not Covered | |
| Orthodontics - 25% Discount off usual and customary fees unless otherwise noted in the provider listing. | ||
| Specialists give a 25% Discount off usual and customary fees unless otherwise noted in the provider listing. | ||
| Lab fees are included in all procedures - no extra lab fees. | ||
| PROCEDURES NOT LISTED: 25% DISCOUNT | ||
| PAYMENT IS DUE AT TIME OF SERVICE. | ||
| PRICES SUBJECT TO CHANGE WITHOUT NOTICE. PLAN CANNOT BE COORDINATED WITH OTHER PROGRAMS OR INSURANCE POLICIES. | ||