ADA CodeProcedure DescriptionMember Pays*
Preventive & Diagnostic
D0120Periodic ExamNO CHARGE
D0140Limited Exam - Problem FocusedNO CHARGE
D0150Comprehensive ExamNO CHARGE
D0210Full Mouth X-RaysNO CHARGE
D0330Panoramic X-RaysNO CHARGE
D1110Adult CleaningNO CHARGE
D1120Child CleaningNO CHARGE
D1351Sealant - Per Tooth20% Off
Restorative
D2330Filling - 1 Surface, Anterior20% Off
D2391Filing - 1 Surface, Posterior20% Off
D2740Crown - Porcelain/Ceramic20% Off
D2750Crown - Porcelain/Metal20% Off
D2950Core Buildup20% Off
Endodontics & Periodontics
D3310Root Canal - Anterior20% Off
D3320Root Canal - Bicuspid20% Off
D3330Root Canal - Molar20% Off
D4341Perio Scaling/Root Planing - 4+ Teeth20% Off
D4910Periodental Maintenance20% Off
Prosthodontics & Oral Surgery
D5110Complete Denture (Upper or Lower)20% Off
D7140Simple Extraction20% Off
D7210Surgical Extraction20% 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.