Savings to Smile About
Below is a list of common dental services and what you’ll pay with Essential Dental Plan.
| Savings Summary | ||
|---|---|---|
| ADA Code | Procedure Description | Member Pays* |
| 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 |
| D0431 | Oral Cancer Screening | NO CHARGE |
| D1110 | Adult Cleaning | $85.00 |
| D1120 | Child Cleaning | $75.00 |
| D1206 | Fluoride - Including Varnish | $35.00 |
| D1351 | Sealant - Per Tooth | $50.00 |
| D2330 | Composite - 1 Surface, Anterior | 15% OFF |
| D2335 | Composite - 4+ Surfaces, Anterior | 15% OFF |
| D2740 | Crown - Porcelain/Ceramic | 15% OFF |
| D2950 | Core Build Up | 15% OFF |
| D3330 | Root Canal - Molar | 15% OFF |
| D4910 | Periodontal Maintenance - Single Visit | $125.00 |
| D7140 | Simple Extraction | 15% OFF |
| D7210 | Surgical Extraction | 15% OFF |
| D9975 | Take-Home Whitening Trays | 15% OFF |
| TBD | Most Other Dental Services | 15% OFF |