ADA CodeProcedure DescriptionMember Pays*
Preventive & Diagnostic
D0120 Periodic Exam NO CHARGE
D0140 Limited Exam - Problem Focused NO CHARGE
D0150 Comprehensive Exam NO CHARGE
D0210 Full Mouth X-Rays NO CHARGE
D0330 Panoramic X-Rays NO CHARGE
D1110 Adult Cleaning NO CHARGE
D1120 Child Cleaning NO CHARGE
D1351 Sealant - Per Tooth 20% Off
Restorative
D2330 Filling - 1 Surface, Anterior 20% Off
D2391 Filing - 1 Surface, Posterior 20% Off
D2740 Crown - Porcelain/Ceramic 20% Off
D2750 Crown - Porcelain/Metal 20% Off
D2950 Core Buildup 20% Off
Endodontics & Periodontics
D3310 Root Canal - Anterior 20% Off
D3320 Root Canal - Bicuspid 20% Off
D3330 Root Canal - Molar 20% Off
D4341 Perio Scaling/Root Planing - 4+ Teeth 20% Off
D4910 Periodental Maintenance 20% Off
Prosthodontics & Oral Surgery
D5110 Complete Denture (Upper or Lower) 20% Off
D7140 Simple Extraction 20% Off
D7210 Surgical Extraction 20% Off

*Member savings may vary by location. No charge exams are limited to a combination of 2 comprehensive or periodic and 1 limited per member per annual membership term. No Charge cleanings are limited to 2 per member per annual membership term.