ADA CodeProcedure DescriptionMember Pays*
DIAGNOSTIC & PREVENTATIVE
D0120 Periodic Exam* FREE
D0140 Limited Oral Evaluation - Problem Focused* FREE
D0150 Comprehensive Oral Evaluation* FREE
D0210 Full Mouth X-Rays* FREE
D1110 Adult Cleaning* FREE
D0220 Periapical X-Ray 20% Off
D1351 Sealant - Per Tooth 20% Off
D0272 Bitewings - 2 Images 20% Off
D0274 Bitewings - 4 Images 20% Off
D0330 Panoramic X-Rays 20% Off
D4341 Perio Scaling/Root Planing - 4+ teeth 20% Off
D4342 Perio scaling / root planing - 1-3 teeth per quad 20% Off
D4910 Periodontal Maintenance 20% Off
D1208 Topical Application of Fluoride 20% Off
RESTORATIVE
D2330 Composite Filling - One Surface, Anterior 20% Off
D2331 Composite Filling - Two Surface, Anterior 20% Off
D2332 Composite Filling - Three Surface, Anterior 20% Off
D2391 Composite Filling - One Surface, Posterior 20% Off
D2392 Composite Filling - Two Surface, Posterior 20% Off
D2393 Composite Filling - Three Surface, Posterior 20% Off
D2740 Crown - Porcelain/Ceramic 20% Off
D2750 Crown - Porcelain/High Noble Metal 20% Off
D2790 Crown - Full Cast High Noble Metal 20% Off
D2930 Crown - Prefab Stainless Steel Crown - Primary Tooth 20% Off
D2950 Core Buildup 20% Off
SPECIALTY
D3120 Pulp Cap - Indirect 20% Off
D3320 Root Canal - Bicuspid 20% Off
D3330 Root Canal - Molar 20% Off
D7140 Simple Extraction 20% Off
D7210 Surgical Extraction 20% Off
D7220/D7230 Removal of Impacted Tooth 20% Off

*Free exams, x-rays, and cleanings are limited to 2 per annual membership term. Services listed on Summary of Discounts, with the exception of Orthodontic services, are performed by your selected general dentist. Certain procedures may not be within the scope of practice or the ability of the general dentist.