Summary of Discounts

ADA
Code
Diagnostic & Preventive You
Pay
D0120 Periodic oral evaluation $25.00
D0140 Limited oral evaluation-problem focused No Charge
D0150 Comprehensive oral evaluation No Charge
D0210 Intraoral - complete series (including bitewings) $25.00
D0220 Intraoral - periapical first film $16.00
D0230 Intraoral - periapical each additional film $14.00
D0330 Panoramic x-ray $50.00
D1110 Prophylaxis - Adult (cleaning & polishing) $60.00
D1120 Prophylaxis - Child (cleaning & polishing) $50.00
D1351 Sealant – per tooth $25.00
D1510 Space maintainer-fixed-unilateral $226.00
D1515 Space maintainer-fixed-bilateral $316.00

Restorative-Fillings

Resin-based composite-anterior
D2330 One surface $119.00
D2331 Two surfaces $149.00
D2332 Three surfaces $172.00
D2335 Four surfaces $215.00
Resin-based composite-posterior
D2391 One surface $122.00
D2392 Two surfaces $172.00
D2393 Three surfaces $192.00
D2394 Four surfaces $297.00

Restorative

D2740 Crown – porcelain/ceramic substrate $966.00
D2750 Crown - porcelain fused to high noble metal $858.00
D2751 Crown - porcelain fused to base metal $743.00
D2930 Prefab stainless steel crown-primary $223.00
D2931 Prefab stainless steel crown-permanent $277.00
D2933 Prefab stainless steel crown w/resin window $183.00
D2940 Protective restoration $79.00
D2950 Crown buildup, Including any pins $185.00
D2952 Cast post & core in add to crown $215.00
D2954 Prefab post & core in add to crown $189.00

Endodontics

D3310 Root canal - anterior $695.00
D3320 Root canal - bicuspid $748.00
D3330 Root canal - molar $949.00

Periodontics

D4341 Periodontal scaling and root planing $171.00
D4342 Perio scaling & root planing-1 to 3 teeth per quad $143.00
D4346 Gingival scaling $90.00
D4355 Full mouth debridement $128.00
D4381 Localized delivery of antimicrobial agents $58.00
D4910 Periodontal maintenance - single visit $97.00

Prosthodontics - Removable

D5110 Complete denture - maxillary (upper) $1,176.00
D5120 Complete denture - mandibular (lower) $1,176.00
D5213 Partial denture maxillary (upper) $1,299.00
D5214 Partial denture mandibular (lower) $1,299.00

Prosthodontics - Fixed

D6240 Pontic-porcelain fused to high noble metal $966.00
D6241 Pontic-porcelain fused to base metal $743.00
D6750 Retainer crown-porcelain fused to high noble metal $858.00
D6751 Retainer crown-porcelain fused-base metal $743.00

Oral Surgery - Extractions

D7140 Extraction erupted tooth $125.00
D7210 Surgical removal of tooth $227.00
D7220 Impacted tooth - soft tissue $283.00
D7230 Impacted tooth - partial Bony $301.00

Orthodontic Services

D8000-D8999 Orthodontic Treatment 30% off UCR

Other Services

D9110 Emergency Treatment, Palliative $197.00
D9230 Nitrous Oxide $74.00
D9910 Application of desensitizing medicament $59.00
D9940 Occlusal guard $441.00
*Participating Dental Providers have agreed to discount their usual and customary fees for services not listed on the Summary of Discounted Fees above, provided those ADA codes or services are offered in office. “Usual” refers to the normal rate charged for the service by the Provider rendering the treatment, and “Customary” is defined as the usual rates of the Providers competitors in the local area. The UCR fee can vary by location.

For a complete summary of your discounts click here

Smile Saver Dental Plan 30% Savings*On services not included on the Summary of Discounts *The 30% discount is the amount you will pay less the Providers Usual and Customary Rate Fee (UCR).

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Savings Examples - The dental plan you need with the savings you deserve.